Application For Accreditation As A Claims Agent Or Attorney printable pdf download

Form Approved, OMB No. 2900-0605

Respondent Burden: 45 minutes

APPLICATION FOR ACCREDITATION AS A CLAIMS AGENT OR ATTORNEY

INSTRUCTIONS: Please provide the applicable personal and employment data, then read each question and provide complete answers to all questions that apply to

you. If additional space is needed, please attach a supplementary page(s). After providing all of the requested information, sign and date your application. Unsigned or

incomplete applications will not be processed. Send completed applications to: Department of Veterans Affairs, Office of the General Counsel (022D), 810 Vermont

Avenue, NW, Washington, D.C. 20420. After an affirmative determination of character and fitness for practice before the VA, claims agent applicants must achieve a

score of 75 percent or more on a written examination administered VA as a prerequisite to acreditation. Claims agent applicants will be given written instructions for

arranging to take the examination if initial eligibility is established. Attorney applicants must be in good standing with a State bar and are not required to take an

examination administered by VA as a prerequisite to accreditation. Denials of initial eligibility for accreditation as a claims agent or attorney are final and are not subject

to appeal, but applicants may reapply.

1. LAST NAME - FIRST NAME - MIDDLE NAME

2A. HOME ADDRESS (street, city, state, ZIP Code)

2B. PHONE NUMBER (Including area code)

2C. E-MAIL ADDRESS (If available)

3A. EMPLOYMENT STATUS

3B. WORK ADDRESS (street, city, state, ZIP Code)

5. PLACE OF BIRTH (City, State, Country)

EMPLOYED (Complete Item 3B)

6. BRANCH OF SERVICE

7. CHARACTER OF DISCHARGE

UNEMPLOYED (Skip Item 3B)