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Standard Form 15 (Rev. 2/90) (EG) …
Tags: address street, announcement number, civil service, fpm, home address, number 9, office of personnel, office of personnel management, periods, point preference, postal service, relatives, social security, social security number, u s office of personnel management, veteran preference, zip code,Pages: 2
Language: english
Created: Thu Aug 21 16:14:40 1997
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Standard Form 15 (Rev. 2/90) (EG) APPLICATION FOR 10-POINT
U.S. Office of Personnel Management
FPM Supplement 296-33 VETERAN PREFERENCE Form Approved:
FPM Chapter 211 (TO BE USED BY VETERANS & RELATIVES OF VETERANS) 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 and ZIP Code)
4. Social Security Number 5. Date Exam Was Held or Application Submitted
VETERAN INFORMATION (to be provided by person applying for preference)
6. Veteran's Name (Last, First, Middle) Exactly As It Appears on Service Records
7. Veteran's Periods of Service 8. Veteran's Social Security Number
Branch of Service From To 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
s
you to the back of this form for the documents you must submit to support your application. (PLEASE NOTE: Eligibility tor veterans' preference is governed by 5 U.S.C. s 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.)
10. VETERAN'S CLAIM FOR PREFERENCE based on non-compensable A and B
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 receipt of A and C
compensation from the VA or disability retirement from a Service Department for
a service-connected disability.
YES NO
12. PREFERENCE FOR A SPOUSE of a living veteran based on the fact that the a. Are you presently married C and H
veteran, because of a service-connected disability, has been unable to qualify
for a Federal or D.C. Government job, or any other position along the lines of to the veteran?
his/her usual occupation. (If your answer to item "a" is "NO", you are ineligible
for preference and need not submit this form.)
13. PREFERENCE FOR WIDOW OR WIDOWER of a veteran. a. Were you married to the A, D, E, and G
(If your answer is "NO" to item "a" or "YES" to item "b", you are ineligible for veteran when he or she died?
preference and need not submit this form.) (Submit G when applicable.)
b. Have you remarried? (Do not
count marriages that were
annulled.)
14. PREFERENCE FOR (NATURAL) MOTHER of a service-connected a. Are you married? DISABLED VETERAN:
permanently and totally disabled, or deceased veteran provided you are or were C, F, and H
married to the father of the veteran, and (Submit F when applicable.)
--- your husband (either the veteran's father or the husband of a remarriage) is b. Are you separated? If "YES",
totally and permanently disabled, or do not complete "c". Go to "d".
--- you are now widowed, divorced, or separated from the veteran's father and
have not remarried, or c. If married now, is your husband DECEASED VETERAN:
--- you are widowed or divorced from the veteran's father and have remarried, totally and permanently A, D, E, and F
but are now widowed, divorced, or separated from the husband of your disabled? (Submit F when applicable.)
remarriage. (if your answer is "NO" to item "c" or "d", you are ineligible for d. If the veteran is dead, did he/
preference and need not submit this form.) she die in active service?
PRIVACY ACT AND PUBLIC BURDEN STATEMENT.
The Veterans' Preference Act of 1944 authorizes the collection of this information. The information you to others from whom information about you is sought. Furnishing your SSN and the other
will be used, along with any accompanying documentation to determine whether you are entitled to information sought is voluntary. However, failure to provide any part of the information may
10-point veterans' preference. This information may be disclosed to: (1) the Department of Veterans result in a ruling that you are not eligible for 10-point veterans' preference or in delaying the
Affairs, or the appropriate branch of the Armed Forces to verify your claim; (2) a court, or a Federal, processing of your application for employment.
State, or local agency for checking on law violations or for other related authorized purposes; (3) a Public burden reporting for this collection of information is estimated to take approximately 10
Federal, State, or local government agency, if you are participating in a special employment minutes per response, including time for reviewing instructions, searching existing data sources,
assistance program; or (4) other Federal, State, or local government agencies, congressional offices, gathering and maintaining the data needed, and completing and reviewing the collection of
and international organizations for purposes of employment consideration, e.g., if you are on an information. Send comments regarding the burden estimate or any other aspect of this collection
Office of Personnel Management list of eligibles. Executive order 9397 authorizes Federal agencies of information, including suggestions for reducing this burden to Reports and Forms
to use the Social Security Number (SSN) to identify individual records in Federal personnel records Management Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Room 6410,
systems. Your SSN will be used to ensure accurate retention of records pertaining to you and may Washington, D.C. 20415; and to the Office of Management and Budget, Paperwork Reduction
also be used to identify Project (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 any Signature of Person Claiming Preference Date Signed
question may be grounds for not employing you, or for dismissing you after you begin work, (Month, Day, Year)
and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001).
FOR USE BY APPOINTING OFFICER ONLY Preference Entitlement Was Verified
Signature and Title of Appointing Officer Name of Agency Date Signed
(Month, Day, Year)
PREVIOUS 7-83 EDITION USABLE 15-110 NSN: 7540-00-634-3972
Designed using Perform Pro, WHS/DIOR, Apr 96
DOCUMENTATION REQUIRED - READ CAREFULLY
(PLEASE SUBMIT PHOTOCOPIES OF DOCUMENTS BECAUSE THEY WILL NOT BE RETURNED)
A. DOCUMENTATION OF SERVICE AND SEPARATION UNDER 3. An official statement or retirement orders from a branch of the
HONORABLE CONDITIONS Armed Forces, showing that the retired serviceman was retired
because of permanent service-connected disability or was
Submit any of the documents listed below as documentation, transferred to the permanent disability retirement list. The
provided they are dated on or after the day of separation from active statement or retirement orders must indicate that the disability is
duty military service: 10% or more.
1. Honorable or general discharge certificate. For spouses and mothers of disabled veterans checking Items 12 or
14, submit the following:
2. Certificate of transfer to Navy Fleet Reserve, Marine Corps Fleet
Reserve, or enlisted Reserve Corps. An official statement, dated within the last 12 months, from the
Department of Veterans Affairs or from a branch of the Armed
3. Orders of Transfer to Retired List. Forces, certifying: 1) the present existence of the veterans
service-connected disability, 2) the percentage and nature of the
4. Report of Separation from a branch of the Armed Forces. service-connected disability or disabilities (including the combined
percentage), 3) a notation as to whether or not the veteran is
5. Certificate of Service or release from active duty, provided currently rated as "unemployable" due to the service-connected
honorable separation is shown. disability, and 4) a notation as to whether or not the service-
connected disability is rated as permanent and total.
6. Official Statement from a branch of the Armed Forces showing
that honorable separation took place.
D. DOCUMENTATION OF VETERAN'S DEATH
7. Notation by the Department of Veterans Affairs or a branch of the
Armed Forces on an official statement, described in B or C below, 1. If on active military duty at time of death, submit official notice,
that the veteran was honorably separated from military service. from a branch of the Armed Forces, of death occurring under
honorable conditions.
8. Official statement from the Military Personnel Records Center that
official service records show that honorable separation took place. 2. If death occurred while not on active military duty, submit death
certificate.
B. DOCUMENTATION OF SERVICE-CONNECTED DISABILITY (NON-
COMPENSABLE, I.E., LESS THAN 10%); PURPLE HEART; AND E. DOCUMENTATION OF SERVICE OR DEATH DURING A WAR, IN A
NONSERVICE-CONNECTED DISABILITY PENSION CAMPAIGN OR EXPEDITION FOR WHICH A CAMPAIGN BADGE IS
AUTHORIZED, OR DURING THE PERIOD OF APRIL 28, 1952
Submit one of the following documents: THROUGH JULY 1, 1955
1. An official statement, dated within the last 12 months, from the Submit documentation of service or death during a war or during the
Department of Veterans Affairs or from a branch of the Armed period April 28, 1952, through July 1, 1955, or during a campaign or
Forces, certifying to the present existence of the veteran's expedition for which a campaign badge is authorized.
service-connected disability of less than 10%.
2. An official citation, document, or discharge certificate, issued by F. DOCUMENTATION OF DECEASED OR DISABLED VETERAN'S
a branch of the Armed Forces, showing the award to the veteran MOTHER'S CLAIM FOR PREFERENCE BECAUSE OF HER
of the Purple Heart for wound or injuries received in action. HUSBAND'S TOTAL AND PERMANENT DISABILITY.
3. An official statement, dated within the last 12 months, from the Submit a statement from husband's physician showing the prognosis
Department of Veterans Affairs, certifying that the veteran is of his disease and percentage of his disability.
receiving a nonservice-connected disability pension.
G. DOCUMENTATION OF ANNULMENT OF REMARRIAGE BY WIDOW
C. DOCUMENTATION OF SERVICE-CONNECTED DISABILITY OR WIDOWER OF VETERAN
(COMPENSABLE, I.E., 10% OR MORE)
Submit either:
Submit one of the following documents, if you checked Item 11 on
the front of this form: 1. Certification from the Department of Veterans Affairs that
entitlement to pension or compensation was restored due to
1. An official statement, dated within the last 12 months, from the annulment.
Department of Veterans Affairs or from a branch of the Armed
Forces, certifying to the veteran's present receipt of compen- 2. A certified copy of the court decree of annulment.
sation for service-connected disability or disability retired pay.
2. An official statement, dated within the last 12 months, from the H. DOCUMENTATION OF VETERAN'S INABILITY TO WORK BECAUSE
Department of Veterans Affairs or from a branch of the Armed OF A SERVICE-CONNECTED DISABILITY
Forces, certifying that the veteran has a service-connected
disability of 10% or more. Answer questions 1 - 7 below:
1. Is the veteran currently working? YES NO 2. If currently working, what is the veteran's present occupation?
If "NO", go to Item 3.
3. What was the veteran's occupation, if any, before military service? 4. What was the veteran's military occupation at the time of separation?
5. Has the veteran been employed, or is he/she now employed, by the Federal civil service or D.C. Government? YES NO
A. Title and Grade of Position Most Recently, or Currently, Held B. Name and Address of Agency C. Dates of Employment
From To
6. Has the veteran resigned from, been disqualified for, or separated from a position in the Federal civil service or D.C.
Government along the lines of his/her usual occupation because of service-connected disability? YES NO
If "YES", submit documentation of the resignation, disqualification, or separation.
7. Is the veteran receiving a civil service retirement pension? YES NO
If "YES", give the Civil Service or Federal Employee retirement annuity number CSA
STANDARD FORM 15 (REV. 2/90) BACK