Standard Form 15 - Application For 10-Point Veteran Preference printable pdf download

STANDARD FORM 15 (REV. 2/90)

APPLICATION FOR 10-POINT

U.S. Office of Personnel Management

VETERAN PREFERENCE

FPM Supplement 296-33

FPM Chapter 211

Form Approved

(TO BE USED BY VETERANS & RELATIVES OF VETERANS)

EXCEPTION TO SF 15, Approved SEP 1999

O.M.B. No. 3206-0001

PERSON APPLYING FOR PREFERENCE

1. NAME (Last, First, Middle)

2. NAME AND ANNOUNCEMENT NUMBER OF CIVIL SERVICE OR POSTAL SERVICE EXAM YOU

HAVE APPLIED FOR OR POSITION WHICH YOU CURRENTLY OCCUPY

3. HOME ADDRESS (Street Number, City, State Zip Code)

4. SOCIAL SECURITY NUMBER

5. DATE EXAM HELD OR RESUME SUBMITTED

VETERAN INFORMATION (to be provided by person applying for preference)

(Last, first, middle)(Exactly as it appears on Service Records)

6. VETERAN’S NAME

7. VETERAN’S PERIOD OF SERVICE

8. VETERAN’S SOCIAL SECURITY NUMBER

BRANCH OF SERVICE

FROM

SERVICE NUMBER

9. VA CLAIM NUMBER, IF ANY

TYPE OF 10-POINT PREFERENCE CLAIMED

INSTRUCTIONS: Check the block which indicates the type of preference you are claiming. Answer all questions associated with that block. The "DOCUMENTATION

REQUIRED" column refers you to the back of this form for the documents you must submit to support your resume. [PLEASE NOTE: Eligibility for veteran’s preference is

governed by 5 U.S.C. A7 2108, 5 CFR Part 211, and FPM chapter 211. All conditions are not fully described in this form because of space restrictions. The office to which

you apply can provide additional information. Instructions on how to apply for five point preference are on SF 171, Application for Federal Employment, or PS Form 2591,

Application for Employment (U.S. Postal Service Application).]

DOCUMENTATION REQUIRED

(See reverse of this form)

A and B

10. VETERAN’S CLAIM FOR PREFERENCE based on non-compensation

service-connected disability; award of the Purple Heart; or receipt of disability

pension under public laws administered by the VA.

11. VETERAN’S CLAIM FOR PREFERENCE based on eligibility for or

A and C

receipt of compensation from the VA or disability retirement from a Service

PERCENT OF DISABILITY

Department for service-connected disability.

12. PREFERENCE FOR A SPOUSE of a living veteran based on the fact that

A. ARE YOU PRESENTLY

C and H

YES

MARRIED TO THE

the veteran, because of a service-connected disability, has been unable to qualify

VETERAN?

for a Federal or D.C. Government job, or any other position along the lines of his

usual occupation. (If your answer to item "A" is "NO", you are ineligible for

preference and need not submit this form.)

A, D, E, and G

A. WERE YOU MARRIED TO

YES

13. PREFERENCE FOR WIDOW OR WIDOWER of a veteran. (If your

VETERAN WHEN HE OR SHE

(Submit G when applicable.)

answer is "NO" to item "A" or "YES" to item "B", you are ineligible for

DIED?

preference and need not submit this form.)

B. HAVE YOU REMARRIED?

YES

(Do not count marriages that

were annulled.)

14. PREFERENCE FOR (NATURAL) MOTHER of a service-connected

A. ARE YOU MARRIED?

YES

DISABLED VETERAN:

permanently and totally disabled, or deceased veteran provided you are or were

C,F, and H

B. ARE YOU SEPARATED?

YES

married to the father of the veteran, and your husband (either the veteran’s father

(Submit F when applicable.)

(If "YES", do not complete "C"

or the husband of a remarriage) is totally and permanently disabled, or you are

Go to "D")

now widowed, divorced, or separated from the veteran’s father and have not

C. IF MARRIED NOW, IS YOUR

YES

remarried, or you are widowed or divorced from the veteran’s father and have

HUSBAND TOTALLY AND

DECEASED VETERAN:

remarried, but are now widowed, divorced, or separated from the husband of your

PERMANENTLY DISABLED?

A, D, E, and F

remarriage. (If your answer is "NO" to item "C" or "D", you are ineligible for

(Submit F when applicable.)

D. IF THE VETERAN IS DEAD

YES

preference and need not submit this form.)

DID HE/SHE DIE IN ACTIVE

SERVICE?

PRIVACY ACT AND PUBLIC BURDEN STATEMENT: The Veterans’

accurate retention of records pertaining to you and may also be used to identify you to

Preference Act of 1944 authorizes the collection of this information. The information

others from whom information about you is sought. Furnishing your SSN and the

will be used, along with any accompanying documentation, to determine whether you

other information sought is voluntary. However, failure to provide any part of the

are entitled to 10-point veterans’ preference. This information may be disclosed to:

information may result in a ruling that you are not eligible for 10-point veterans’

(1) the Department of Veterans Affairs, or the appropriate branch of the Armed

preference or in delaying the processing of your resume for employment. Public

Forces to verify your claim; (2) a court, or Federal;, State, or local agency for

burden reporting for this collection of information is estimated to take approximately

checking on law violations or for other related authorized purposes; (3) a Federal,

10 minutes per response, including time for reviewing instructions, searching existing

State, or local government agency, if you are participating in a special employment

data sources, gathering and maintaining the data needed, and completing and

assistance program; or (4) other Federal, State, or local government agencies,

reviewing the collection of information. Send comments regarding the burden

congressional offices, and international organizations for purposes of employment

estimate or any other aspect of this collection of information, including suggestions

consideration, e.g., if you are on an Office of Personnel Management list of eligibles.

for reducing this burden, to Reports and Forms Management Officer, U.S. Office of

Executive order 9397 authorizes Federal agencies to use the Social Security Number

Personnel Management, 1900 E Street, N.W., Room 6410, Washington, D.C. 20415;

(SSN) to identify individual records in Federal personnel records or systems. Your

and to the Office of Management and Budget, Paperwork Reduction Project

SSN will be used to ensure

(3206-0001), Washington, D.C. 20503.

THIS FORM MUST BE SIGNED BY ALL PERSONS CLAIMING 10-POINT PREFERENCE

I certify that all of the statements made in this claim are true, complete, and correct to

the best of my knowledge and belief and are made in good faith. [A false answer to

SIGNATURE AND TITLE OF PERSON CLAIMING PREFERENCE

DATE SIGNED

any question may be grounds for not employing you, or for dismissing you after you

(Month, Day, Year)

begin work, and may be punishable by fine or imprisonment (U.S. Code, Title18,

Section 1001).]

PREFERENCE ENTITLEMENT WAS VERIFIED

DATE SIGNED

FOR USE BY APPOINTING OFFICER ONLY

NAME OF AGENCY

(Month, Day, Year)

SIGNATURE AND TITLE OF APPOINTING OFFICER

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Standard Form 15 - Application For 10-Point Veteran Preference

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