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Eligibility Data Form VETS-USERRA-VP-1010 - Official Federal Forms
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OMB NO. 1293-0002 (EXP 03/31/2007) VETS/USERRA/VP Form 1010 (REV 2/99) ELIGIBILITY DATA FORM: For claims under the Uniformed Services Employment and Reemployment Rights Act (USERRA) and/or claims under the Veterans Preference (VP) provisions of the Veterans Employment Opportunities Act of 1998 U.S. Department of Labor, Veterans Employment and Training Service PLEASE TYPE OR PRINT Section I: Claimant Information 1. Name: __________________________________________________________________________________________________________________ Last Name First Name M.I. 2. Address: _________________________________________________________________________________________________________________ Street City State ZIP 3. Social Security No: _________________________ 4. Home Phone: _________________________ 5. Work Phone: _______________________ Section II: Uniformed Service Information 6. Serve(d) In: ? Army ? Navy ? Marine Corps ? Air Force ? Coast Guard ? National Guard ? Reserve ? Public Health Service ? Other (Explain in Comments) ? None (Retaliation Claim Explain in Comments) 7. If Reserve/National Guard: (a) Name of Unit: _______________________________________________________________________________ (b) Unit Address: _______________________________________________________________________________ (c) Unit Phone: _______________________________ 8. Dates of Service (If applicable): (a) From: ________________ To: _______________ OR (b) Date of Examination/Rejection for Service: ________________ 9. Type of Discharge or Separation: ? Honorable Conditions ? Entry Level ? Uncharacterized ? Medical ? Other than Honorable Conditions ? Other (Explain in Comments) ? Not Applicable Section III: Employer Information 10. Employer or Prospective Employers Name: _______________________________________________________________________ 11. Address: __________________________________________________________________________________________________________ Street City County State ZIP 12. Principal Employer Contact (PEC): (a) PEC Name/Title: ___________________________________________ (b) PEC Phone: __________________________________________ 13. Employment Dates (If applicable): From: ____________________ To: ____________________ 14. Since beginning work with this employer, has your cumulative uniformed service exceeded 5 years? ? Yes ? No If YES, explain in Comments box at end of this claim form. 15. Name of Union(s) That Represent You: ______________________________________________________ <<<<<<<<<********>>>>>>>>>>>>> 2 Section IV: Claim Information If Claim Concerns Veterans Preference in Federal Employment 16. Preference Issue (Check One): ? Hiring ? Reduction-in-Force (RIF) If Claim Concerns Employment Discrimination under USERRA 17. Employment Discrimination Issue(s): ? Hiring ? Reemployment ? Promotion ? Termination ? nefits of EmploymentBe If Claim Concerns Hiring, Promotion, RIF or Termination 18. Title of Position Held or Applied For: _____________________________________________________________ 19. Pay Rate: __________________________ 20. Date of Application Employment/Promotion: ________________________ 20a. Vacancy Announcement No.: ______________________________________________________________________ 20b. Date Vacancy Opened: __________________________ 20c. Date Vacancy Closed: _________________________ If Claim Concerns Reemployment Following Service 21. Was Prior Notice of Service Provided to Employer? ? Yes ? No (If No, Explain in Comments) 22. (a) Who Provided Notice of Service to Employer? ? Self ? Other (name): _______________________________________ (b) Was the Notice of Service: ? Written ? Oral ? Both (c) Date Notice of Service was given to Employer: _______________________ 23. Name/Title of Person to Whom Notice of Service was Provided: _________________________________________ 24. Date Applied for Reemployment: ______________________ OR Date Returned to Work: ______________________ 25. Reemployment Application Made To: Name: _________________________________ Title: _____________________________ 26. Reemployed or Reinstated? ? Yes (date): ______________________ ? No (a) If YES, what position? ____________________________________ at what pay rate? ________________________ (b) If NO, Date denied: ___________________ Reason given: ______________________________________________ (c) Who denied (name): ____________________________________ PUNISHMENT FOR UNLAWFUL STATEMENTS The information provided in this complaint will be utilized by the U.S. Department of Labor, Veterans Employment and Training Service (VETS) to initiate an investigation of alleged violations of the Uniformed Service Employment and Reemployment Rights Act (USERRA) and/or the Veterans Preference (VP) provisions of the Veterans Employment Opportunities Act of 1998 (VEOA). Potential claimants should keep in mind that it is unlawful to knowingly and willfully make any materially false, fictitious, or fraudulent statements or representation to a federal agency. Violations can be punished under Section 2 of the False Statements Accountability Act of 1996 by a fine and/or imprisonment of not more than 5 years. 18 U.S.C. 1001. I certify that the above information is true and correct to the best of my knowledge and belief. I authorize the U.S. Department of Labor to contact my employer or any other person for information concerning this claim. Pursuant to 5 U.S.C., Section 552(b) of the Privacy Act, I consent to the release of the above information and any records necessary for the investigation and prosecution of my claim. SIGNATURE: ___________________________________________________________ DATE: _________________________________ Persons are not required to response to the collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Veterans Employment and Training Service, Room-S1316, 200 Constitution Avenue, N.W., Washington, DC 20210. PRIVACY ACT STATEMENT The primary use of this information is by staff of the Veterans Employment an
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