<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 12%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 10%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 15%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="4">U.S. Office of Personnel Management</td>
<td colspan="14"><h1 id="application-for-10-point">APPLICATION FOR
10-POINT</h1>
<h1 id="veteran-preference">VETERAN PREFERENCE</h1>
<h1 id="to-be-used-by-veterans-relatives-of-veterans">(TO BE USED BY
VETERANS &amp; RELATIVES OF VETERANS)</h1></td>
<td colspan="4"><p>Form Approved</p>
<p>O.M.B. No. 3206-0001</p></td>
</tr>
<tr class="even">
<td colspan="22"><strong>PERSON APPLYING FOR PREFERENCE</strong></td>
</tr>
<tr class="odd">
<td colspan="8">1. Name <em>(Last, First, Middle)</em></td>
<td colspan="14" rowspan="2">2. Name of Civil Service or Postal Service
exam and/or job announcement number<br />
you have applied for or position which you currently occupy</td>
</tr>
<tr class="even">
<td colspan="8" rowspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="14" rowspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="8">3. Home address <em>(Street Number, City, State and ZIP
Code)</em></td>
</tr>
<tr class="odd">
<td colspan="8" rowspan="2"><strong>     </strong></td>
<td colspan="7">4. Social Security Number</td>
<td colspan="7">5. Date exam was held or application submitted</td>
</tr>
<tr class="even">
<td colspan="7"><strong>Not Required (leave blank)</strong></td>
<td colspan="7"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="22"><strong>VETERAN INFORMATION <em>(to be provided by
person applying for preference)</em></strong></td>
</tr>
<tr class="even">
<td colspan="22">6. Veteran’s name <em>(Last, First, Middle)</em>
exactly as it appears on Service Records</td>
</tr>
<tr class="odd">
<td colspan="22"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="16">7. Veteran’s periods of service</td>
<td colspan="6">8. Veteran’s Social Security Number</td>
</tr>
<tr class="odd">
<td colspan="3">Branch of Service</td>
<td colspan="4">From</td>
<td colspan="4">To</td>
<td colspan="5">Service Number</td>
<td colspan="6"><strong>Not Required (leave blank)</strong></td>
</tr>
<tr class="even">
<td colspan="3" rowspan="2"><strong>     </strong></td>
<td colspan="4" rowspan="2"><strong>     </strong></td>
<td colspan="4" rowspan="2"><strong>     </strong></td>
<td colspan="5" rowspan="2"><strong>     </strong></td>
<td colspan="6">9. VA claim number, if any</td>
</tr>
<tr class="odd">
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="22"><strong>TYPE OF 10-POINT PREFERENCE
CLAIMED</strong></td>
</tr>
<tr class="odd">
<td colspan="22"><p><strong>INSTRUCTIONS:</strong> Check the block which
indicates the type of preference you are claiming. Answer all questions
associated with that block. The <strong>Documentation Required</strong>
column refers you to the back of this form for the documents you must
submit to support your application. (<strong>Please Note:</strong>
Eligibility for veterans’ preference is governed by 5 U.S.C. 2108, 5 CFR
Part 211.<br />
All conditions are not fully described on this form because of space
restrictions. The office to which you apply can provide additional
information.) <strong>Documentation Required</strong></p>
<p><em>(See reverse of this form)</em></p></td>
</tr>
<tr class="even">
<td rowspan="3"></td>
<td rowspan="3">10.</td>
<td colspan="11" rowspan="3"><p><strong>Veteran’s Claim for
Preference</strong> based on non-compensable</p>
<p>service-connected disability; award of the Purple Heart; or receipt
of disability pension under public laws administered by the VA.</p></td>
<td
colspan="8">---------------------------------------------------------------</td>
<td rowspan="2">A and B</td>
</tr>
<tr class="odd">
<td colspan="8"></td>
</tr>
<tr class="even">
<td colspan="8"></td>
<td></td>
</tr>
<tr class="odd">
<td rowspan="2"></td>
<td rowspan="2">11.</td>
<td colspan="11" rowspan="2"><strong>Veteran’s Claim for
Preference</strong> based on eligibility for or receipt of compensation
from the VA or disability retirement from a Service Department for a
service-connected disability.</td>
<td
colspan="8">---------------------------------------------------------------</td>
<td rowspan="2">A and C</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"><strong>YES</strong></td>
<td colspan="2"><strong>NO</strong></td>
</tr>
<tr class="odd">
<td rowspan="2"></td>
<td rowspan="2">12</td>
<td colspan="11" rowspan="2"><strong>Preference for a Spouse</strong> of
a living veteran based on the fact that the 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 his/her
usual occupation. (If your answer to item A is <em>No</em>, you are
ineligible for preference and need not submit this form.)</td>
<td colspan="4" rowspan="2"><p>a. Are you presently married</p>
<p>to do veteran?</p></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td rowspan="2">C and H</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td rowspan="2"></td>
<td rowspan="2">13.</td>
<td colspan="11" rowspan="2"><p><strong>Preference for a Widow or
Widower of a veteran.</strong></p>
<p>(If your answer is <em>No</em> to item A or <em>Yes</em> to item B,
you are ineligible for</p>
<p>preference and need not submit this form.)</p></td>
<td colspan="4">a. Were you married to the<br />
veteran when he or she died?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td rowspan="2"><p>A,D,E, and G</p>
<p>(Submit G when applicable.)</p></td>
</tr>
<tr class="even">
<td colspan="4"><p>b. Have you remarried?</p>
<p>(Do not count marriages</p>
<p>that were annulled.)</p></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td rowspan="4"></td>
<td rowspan="4">14.</td>
<td colspan="11" rowspan="4"><p><strong>Preference for (Natural)
Mother</strong> of a service-connected</p>
<p>permanently and totally disabled, or deceased veteran provided you
are or were married to the father of the veteran, and</p>
<p>---your husband (either the veteran’s father or the husband of a
remarriage) is totally and permanently disabled, or</p>
<p>---you are now widowed, divorced, or separated from the veteran’s
father and have not remarried, or</p>
<p>---you are widowed or divorced from the veteran’s father and have
remarried, but are now widowed, divorced, or separated from the husband
of your remarriage. (If your answer is <em>No</em> to item C or D, you
are ineligible for preference and need not submit this form.)</p></td>
<td colspan="4">a. Are you married?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td rowspan="2"><p><strong>Disabled Veteran</strong></p>
<p>C, F AND H</p>
<p>(Submit F when applicable.)</p></td>
</tr>
<tr class="even">
<td colspan="4"><p>b. Are you separated? If <em>Yes</em>,</p>
<p>do not complete C, go to D.</p></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4">c. If married now, is your<br />
husband totally and<br />
permanently disabled?</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td rowspan="2"><p><strong>Deceased Veteran</strong></p>
<p>A,D,E, AND F</p>
<p>(Submit F when applicable.)</p></td>
</tr>
<tr class="even">
<td colspan="4">d. If the veteran is dead, did he/<br />
she die in active service?</td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="10"><p><strong>PRIVACY ACT AND PUBLIC BURDEN
STATEMENT</strong></p>
<p>The Veterans’ Preference Act of 1944 authorizes the collection of
this information. The information will be used, along with any
accompanying documentation to determine whether you are entitled to 10
point veterans’ preference. This information may be disclosed to: (1)
the Department of Veterans Affairs, or the appropriate branch of the
Armed Forces to verify your claim; (2) a court, or a Federal, State, or
local agency for checking on law violations or for other related
authorized purposes; (3) a Federal, State, or local government agency,
if you are participating in a special employment assistance program; or
(4) other Federal, State, or local government agencies, congressional
offices, and international organizations for purposes of employment
consideration, e.g., if you are on an Office of Personnel Management or
other list of eligibles. Executive Order 9397 (November 22, 1943)
authorizes Federal agencies to use an individual’s Social Security
Number (SSN) to identify individual records in Federal personnel records
systems. Your SSN will be used to ensure accurate retention of records
pertaining to you and may also be used to identify you to others from
whom</p></td>
<td colspan="12"><p>information about you is sought. Furnishing your SSN
and the other information sought is</p>
<p>voluntary. However, failure to provide any part of the information
may result in a ruling that you</p>
<p>are not eligible for 10-point veterans’ preference or in delaying the
processing of your application</p>
<p>for employment.</p>
<p>Public burden reporting for this collection of information is
estimated to take approximately 10</p>
<p>minutes per response, including time for reviewing instructions,
searching existing data sources,</p>
<p>gathering and maintaining the data needed, and completing and
reviewing the collection of</p>
<p>information. Send comments regarding the burden estimate or any other
aspect of this collection</p>
<p>of information, including suggestions for reducing this burden to OPM
Forms Officer, U.S. Office</p>
<p>of Personnel Management, Washington, D.C. 20415; The OMB Number,
3206-0001, is currently valid. OPM may not collect this information and
you are not required to respond, unless this number is
displayed.</p></td>
</tr>
<tr class="even">
<td colspan="9" rowspan="3"><strong>I certify</strong> 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 question may be grounds for not employing you, or for
dismissing you after you begin work, and may be punishable by fine or
imprisonment (U.S. Code, Title 18, Section 1001).</td>
<td colspan="13"><em><strong>This form must be signed by all persons
claiming 10-Point preference</strong></em></td>
</tr>
<tr class="odd">
<td colspan="11">Signature of Person Claiming Preference</td>
<td colspan="2"><p>Date Signed</p>
<p><em>(Month, Day, Year)</em></p></td>
</tr>
<tr class="even">
<td colspan="11"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="9">FOR USE BY APPOINTING OFFICIER ONLY</td>
<td colspan="3"></td>
<td colspan="8">Preference Entitlement Was Verified</td>
<td colspan="2" rowspan="2"><p>Date Signed</p>
<p><em>(Month, Day, Year)</em></p></td>
</tr>
<tr class="even">
<td colspan="5">Signature of Appointing Officer</td>
<td colspan="4">Title</td>
<td colspan="11">Name of Agency</td>
</tr>
<tr class="odd">
<td colspan="5"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="11"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="6"><p>Previous editions not usable</p>
<p>5 CFR 211</p></td>
<td colspan="8"></td>
<td colspan="8"><p>Standard Form 15</p>
<p>Revised December 2004</p>
<p>NSN-7540-00-634-3972</p></td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 27%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 18%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 11%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="12"><h1
id="documentation-required---read-carefully">DOCUMENTATION REQUIRED -
READ CAREFULLY</h1></td>
</tr>
<tr class="even">
<td colspan="12"><em>Please submit photocopies of documents because they
will <strong>not</strong> be returned unless a certified copy is
specified.</em></td>
</tr>
<tr class="odd">
<td colspan="5"><p><strong>A. Documentation of Service and Separation
under Honorable</strong></p>
<p><strong>Conditions</strong></p>
<blockquote>
<p><em>Submit any of the documents listed below</em> as
documentation,</p>
<p>provided they are dated on or after the day of separation from
active</p>
<p>duty military service:</p>
</blockquote>
<ol type="1">
<li><p>Honorable or general discharge certificate.</p></li>
<li><p>Certificate of transfer to Navy Fleet Reserve, Marine Corps Fleet
Reserve, or enlisted Reserve Corps.</p></li>
<li><p>Orders of transfer to retired list.</p></li>
<li><p>Report of separation from a branch of the Armed Forces.</p></li>
<li><p>Certificate of service or release from active duty,
provided<br />
honorable separation is shown.</p></li>
<li><p>Official statement from a branch of the Armed Forces
showing<br />
that honorable separation took place.</p></li>
<li><p>Notation by the Department of Veterans Affairs or a branch of the
Armed Forces on an official statement, described in B or C below,<br />
that the veteran was honorably separated from military service.</p></li>
<li><p>Official statement from the Military personnel records center
that official service records show that honorable separation took
place.</p></li>
</ol>
<p><strong>B. Documentation of Service-Connected Disability<br />
(Non-Compensable, i.e., Less than 10%); Purple Heart; and<br />
Nonservice-Connected Disability Pension.</strong></p>
<blockquote>
<p><em>Submit one</em> of the following documents:</p>
</blockquote>
<ol type="1">
<li><p>An official statement, <em>dated 1991 or later,</em> from
the</p></li>
</ol>
<blockquote>
<p>Department of Veterans Affair or from a branch of the Armed</p>
<p>Forces, certifying to the present existence of the veteran’s</p>
<p>service-connected disability of less than 10%.</p>
</blockquote>
<ol start="2" type="1">
<li><p>An official citation, document, or discharge certificate issued
by a branch of the Armed Forces, showing the award to the veteran<br />
of the Purple Heart for wound or injuries received in action.</p></li>
<li><p>An official statement <em>dated 1991 or later,</em> from
the<br />
Department of Veterans Affairs, certifying that the veteran is<br />
receiving a nonservice-connected disability pension.</p></li>
</ol>
<p><strong>C. Documentation of Service-Connected Disability<br />
(Compensable, i.e., 10% or More).</strong></p>
<blockquote>
<p>If you checked item 11 on the front of this form, <em>submit one</em>
of the</p>
<p>following documents:</p>
</blockquote>
<ol type="1">
<li><p>An official statement <em>dated 1991 or later</em>, from the
Department<br />
of Veterans Affairs or from a branch of the Armed Forces,<br />
certifying to the veteran’s present receipt of compensation<br />
for service-connected disability or disability retired pay.</p></li>
<li><p>An official statement <em>dated 1991 or later,</em> from the
Department<br />
of Veterans Affairs or from a branch of the Armed Forces,<br />
certifying that the veteran has a service-connected disability<br />
of 10% or more.</p></li>
</ol></td>
<td colspan="7"><ol start="3" type="1">
<li><p>An official statement or retirement orders from a branch of
the<br />
Armed Forces, showing that the retired serviceman was retired because of
permanent service-connected disability or was<br />
transferred to the permanent disability retirement list. The<br />
statement or retirement orders must indicate that the disability
is<br />
10% or more.</p></li>
</ol>
<blockquote>
<p>For spouses and mothers of disabled veterans checking items 12
or<br />
14, submit the following:</p>
</blockquote>
<p>An official statement <em>dated 1991 or later,</em> from the
Department of Veterans Affairs or from a branch of the Armed Forces,
certifying:</p>
<p>1) the present existence of the veterans service-connected
disability,</p>
<p>2) the percentage and nature of the service-connected disability
or<br />
disabilities (including the combined percentage),</p>
<p>3) a notation as to whether or not the service-connected disability
is<br />
rated as permanent and total.</p>
<p><em><strong>Please Note:</strong></em> When a veteran dies on active
duty, the family does not receive a DD Form 214; the family receives a
DD Form 1300, Report of Casualty, on which there is no place to record
the character of service. Thus, when a veteran dies on active duty, his
or her service should be presumed to be under honorable conditions
unless the military service specifically indicates otherwise.</p>
<p><strong>D. Documentation of Veteran’s Death</strong></p>
<ol type="1">
<li><p>If on active military duty at time of death, submit official
notice, from a branch of the Armed Forces, of death occurring under
honorable conditions.</p></li>
<li><p>If death occurred while not on active military duty,
<em>submit</em> certified copy of death certificate.</p></li>
</ol>
<ol start="5" type="A">
<li><p><strong>Documentation of Service or Death During a War, in a
Campaign or Expedition for which a Campaign Badge is Authorized, or
During the Period Authorized, or During the Period of April 28, 1952
through July 1, 1955.</strong></p></li>
</ol>
<blockquote>
<p><em>Submit</em> documentation of service or death during a war or
during the period April 28, 1952, through July 1, 1955, or during a
campaign or expedition for which a campaign badge is authorized.</p>
</blockquote>
<p><strong>F. Documentation of Deceased or Disabled Veteran’s
Mother’s<br />
Claim for Preference because of Her Husband’s Total and<br />
Permanent Disability.</strong></p>
<blockquote>
<p>Submit a statement from husband’s physician showing the prognosis of
his disease and percentage of his disability.</p>
</blockquote>
<p><strong>G. Documentation of Annulment of Remarriage by Widow or
Widower<br />
of Veteran.</strong></p>
<blockquote>
<p><em>Submit</em> either:</p>
</blockquote>
<ol type="1">
<li><p>Certificate from the Department of Veterans Affairs that<br />
entitlement to pension or compensation was restored due to
annulment.</p></li>
<li><p>A certified copy of the court decree of annulment.</p></li>
</ol>
<p><strong>H. Documentation of Veteran’s Inability to Work Because
of<br />
a Service-Connected Disability.</strong></p>
<p><em>Answer</em> questions 1-7 below:</p></td>
</tr>
<tr class="even">
<td rowspan="2">1. Is the veteran currently working?<br />
If “No”, go to item 3.</td>
<td> Yes</td>
<td colspan="5"> No</td>
<td colspan="5">2. If currently working, what is the veteran’s present
occupation?</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="5"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="7">3. What was the veteran’s occupation, if any before
military service?</td>
<td colspan="5">4. What was the veteran’s military occupation at the
time of separation?</td>
</tr>
<tr class="odd">
<td colspan="7"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="9">5. Has the veteran been employed, or is he/she now
employed, by the Federal civil service or D.C. Government?</td>
<td colspan="2"> Yes</td>
<td> No</td>
</tr>
<tr class="odd">
<td colspan="4">A. Title and Grade of position most recently, or
currently, Held</td>
<td colspan="5">B. Name and Address of Agency</td>
<td colspan="3">C. Dates of Employment</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="2"><strong>     </strong></td>
<td colspan="5" rowspan="2"><strong>     </strong></td>
<td colspan="2">From</td>
<td>To</td>
</tr>
<tr class="odd">
<td colspan="2"><strong>     </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="9"><p>6. Has the veteran resigned from, been disqualified
for, or separated from a position in the Federal civil service or</p>
<p>D.C. Government along the lines of his/her usual occupation because
of service-connected disability?</p>
<p>If <em>Yes,</em> submit documentation of the resignation,
disqualification, or separation.</p></td>
<td colspan="2"> Yes</td>
<td> No</td>
</tr>
<tr class="odd">
<td colspan="3">7. Is the veteran receiving a civil service retirement
pension?</td>
<td colspan="3"> Yes</td>
<td colspan="6"> No</td>
</tr>
<tr class="even">
<td colspan="8"> If Yes, give the Civil Service or Federal Employee
retirement annuity number _______________________________</td>
<td colspan="2">CSA #</td>
<td colspan="2"><strong>     </strong></td>
</tr>
</tbody>
</table>

> Standard Form 15 (back)\
> Revised December 2004