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<tr class="odd">
<td colspan="3"><p>Standard Form 15 (Rev. 2/90) (EG)</p>
<p>U.S. Office ot Personnel Management</p>
<p>FPM Supplement 296-33</p>
<p>FPM Chapter 211</p></td>
<td colspan="15"><p><strong>APPLICATION FOR 10-POINT</strong></p>
<p><strong>VETERAN PREFERENCE</strong></p>
<p><strong>(TO BE USED BY VETERANS &amp; RELATIVES OF
VETERANS)</strong></p></td>
<td colspan="4"><p>Form Approved:</p>
<p>O.M.B. Nn 3206-000l</p></td>
</tr>
<tr class="even">
<td colspan="22"><strong>PERSON APPLYING FOR PREFERENCE</strong></td>
</tr>
<tr class="odd">
<td colspan="7">1. Name (Last, First, Middle)</td>
<td colspan="15" rowspan="2">2. Name and Announcement Number of Civil
Service or Postal Service Exam You<br />
Have Applied For or Position Which You Currently Occupy</td>
</tr>
<tr class="even">
<td colspan="7" rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="15" rowspan="3">     </td>
</tr>
<tr class="even">
<td colspan="7">3. Home Address (Street Number, City, State and ZIP
Code)</td>
</tr>
<tr class="odd">
<td colspan="7" rowspan="3">     </td>
</tr>
<tr class="even">
<td colspan="4">4. Social Security Number</td>
<td colspan="11">5. Date Exam Was Held or Application Submitted</td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
<td colspan="11">     </td>
</tr>
<tr class="even">
<td colspan="22"><strong>VETERAN INFORMATION <em>(to be provided by
person applying for preference)</em></strong></td>
</tr>
<tr class="odd">
<td colspan="22">6. Veteran’s Name (Last, First, Middle) Exactly As It
Appears on Service Records</td>
</tr>
<tr class="even">
<td colspan="22">     </td>
</tr>
<tr class="odd">
<td colspan="11">7. Veteran’s Periods of Service</td>
<td colspan="11">8 Veteran’s Social Security Number</td>
</tr>
<tr class="even">
<td colspan="2">Branch of Service</td>
<td colspan="3">From</td>
<td colspan="2">To</td>
<td colspan="4">Service Number</td>
<td colspan="11">     </td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="2">     </td>
<td colspan="3" rowspan="2">     </td>
<td colspan="2" rowspan="2">     </td>
<td colspan="4" rowspan="2">     </td>
<td colspan="11">9. VA Claim Number, If Any</td>
</tr>
<tr class="even">
<td colspan="11">     </td>
</tr>
<tr class="odd">
<td colspan="22">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
application. (PLEASE NOTE: Eligibility tor veterans’ preference is
governed by 5 U.S.C. s 2108, 5 CFR Part 2l 1, 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).</td>
</tr>
<tr class="even">
<td colspan="22"></td>
</tr>
<tr class="odd">
<td colspan="14"></td>
<td colspan="8">DOCUMENTATION REQUIRED<br />
(See reverse of this form.)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7">10. VETERAN’S CLAIM FOR PREFERENCE based on
non-compensable<br />
service-connected disability; award of the Purple Heart; or receipt of
disability<br />
pension under public laws administered by the VA.</td>
<td colspan="12"></td>
<td colspan="2">A and B</td>
</tr>
<tr class="odd">
<td colspan="22"></td>
</tr>
<tr class="even">
<td rowspan="3"></td>
<td colspan="7" rowspan="3">11. VETERAN’S CLAIM FOR PREFERENCE based on
eligibility for or receipt of<br />
compensation from the VA or disability retirement from a Service
Department<br />
for a service-connected disability.</td>
<td colspan="12"></td>
<td colspan="2">A and C</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">Percent of Disability</td>
<td colspan="4"></td>
<td colspan="2" rowspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">     </td>
<td colspan="5">%</td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="22"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="7">12. PREFERENCE FOR A SPOUSE 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 “NO”, you are ineligible for preference and need
not submit this form.)</td>
<td colspan="4"><blockquote>
<p>a. Are you presently married to the veteran?</p>
</blockquote></td>
<td></td>
<td colspan="2">Yes</td>
<td colspan="2"></td>
<td colspan="2">No</td>
<td colspan="3">C and H</td>
</tr>
<tr class="odd">
<td colspan="22"></td>
</tr>
<tr class="even">
<td rowspan="5"></td>
<td colspan="7" rowspan="5">13. PREFERENCE FOR WIDOW OR WIDOWER of a
veteran. (If your answer is “NO” to item “a” or “YES” to item “b”, you
are ineligible for preference and need not submit this form.)</td>
<td colspan="4" rowspan="3">a. Were you married to the veteran when he
or she died?</td>
<td rowspan="3"></td>
<td colspan="2" rowspan="3">Yes</td>
<td colspan="2" rowspan="3"></td>
<td colspan="2" rowspan="3">No</td>
<td colspan="3" rowspan="5"><p>A, D, E, and G</p>
<p>(Submit G when applicable.)</p></td>
</tr>
<tr class="odd">
</tr>
<tr class="even">
</tr>
<tr class="odd">
<td colspan="4" rowspan="2">b. Have you remarried? (Do not count
marriages that were annulled.)</td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2">Yes</td>
<td colspan="2" rowspan="2"></td>
<td colspan="2" rowspan="2">No</td>
</tr>
<tr class="even">
</tr>
<tr class="odd">
<td rowspan="12"></td>
<td colspan="7" rowspan="12"><blockquote>
<p>14. PREFERENCE FOR (NATURAL) MOTHER of a service-connected
permanently and totally disabled, or deceased veteran provided you are
or were married to the father of the veteran, and your husband (either
the veteran’s father or the husband of a remarriage) is totally and
permanently disabled, or you are now widowed, divorced, or separated
from the veteran’s father and have not remarried, or 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 “NO” to item “c” or “d”, you are ineligible for
preference and need not submit this form.)</p>
</blockquote></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4">a. Are you married?</td>
<td></td>
<td colspan="2">Yes</td>
<td colspan="2"></td>
<td colspan="2">No</td>
<td colspan="3">DISABLED VETERAN:</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3">C, F, and H</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="2"><blockquote>
<p>b. Are you separated? If “YES”, do not complete “c”. Go to “d”.</p>
</blockquote></td>
<td></td>
<td colspan="2">Yes</td>
<td colspan="2"></td>
<td colspan="2">No</td>
<td colspan="3">(Submit F when applicable.)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"><blockquote>
<p>c. If married now, is your husband totally and permanently
disabled?</p>
</blockquote></td>
<td></td>
<td colspan="2">Yes</td>
<td colspan="2"></td>
<td colspan="2">No</td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3">DECEASED VETERAN:</td>
</tr>
<tr class="even">
<td colspan="4">d. If the veteran is dead, did he/she</td>
<td></td>
<td colspan="2">Yes</td>
<td colspan="2"></td>
<td colspan="2">No</td>
<td colspan="3">A, D, E, and F</td>
</tr>
<tr class="odd">
<td colspan="4">die in active service?</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3">(Submit F when applicable.)</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="8"><strong>PRIVACY ACT AND PUBLIC BURDEN
STATEMENT.</strong> 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: (I)
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, <em>e.g</em>., if you are on an Office of Personnel
Management list of eligibles. Executive order 9397 authorizes Federal
agencies to use the Social Security Number (SSN) to identify individual
records in Federal personnel records or systems. Your SSN will be used
to ensure accurate retention of records pertaining to you and may</td>
<td colspan="14">also be used to identify you to others from whom
information about you is sought. Furnishing your SSN and the other
information sought is voluntary. However, failure to provide any part of
the information may result in a ruling that you are not eligible for
10-point veterans’ preference or in delaying the processing of your
application for employment Public burden reporting for this collection
of information is estimated to take approximately 10 minutes per
response, including 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 the
burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to Reports and Forms
Management Officer, U.S. Office of Personnel Management, 1900 E Street,
NW., Room 6410, 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</td>
</tr>
<tr class="even">
<td colspan="8" rowspan="4">I certify that all of the statements made in
this claim are true, complete, and correct to thebest 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="14"><strong>This Form Must Be Signed By All Persons
Claiming 10-Point Preference</strong></td>
</tr>
<tr class="odd">
<td colspan="13">Signature of Person Claiming Preference</td>
<td>Date Signed</td>
</tr>
<tr class="even">
<td colspan="13" rowspan="3"></td>
<td><em>(Month, Day, Year)</em></td>
</tr>
<tr class="odd">
<td rowspan="2">     </td>
</tr>
<tr class="even">
<td colspan="8"></td>
</tr>
<tr class="odd">
<td colspan="8"><strong>FOR USE BY APPOINTING OFFICER ONLY</strong></td>
<td colspan="13"> Preference Entitlement Was Verified</td>
<td>Date Signed</td>
</tr>
<tr class="even">
<td colspan="8"><strong>Signature and Title of Appointing
Officer</strong></td>
<td colspan="13">Name of Agency</td>
<td><em>(Month, Day, Year)</em></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="4">     </td>
<td colspan="13">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="6">PREVIOUS 7-83 EDITION USABLE</td>
<td colspan="4">15-1 10</td>
<td colspan="12">NSN: 7540-00-634-3972<br />
Designed using Perform Pro, WHS/DIOR, Apr 96</td>
</tr>
</tbody>
</table>

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<tbody>
<tr class="odd">
<td colspan="12"><strong>DOCUMENTATION REQUIRED - READ CAREFULLY<br />
(PLEASE SUBMIT PHOTOCOPIES OF DOCUMENTS BECAUSE THEY WILL NOT BE
RETURNED)</strong></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="5"><p>A. DOCUMENTATION OF SERVICE AND SEPARATION UNDER
HONORABLE CONDITIONS</p>
<blockquote>
<p>Submit any of the documents listed below as documentation, provided
they are dated on or after the day of separation from active duty
military service:</p>
<p>1. Honorable or general discharge certificate.</p>
<p>2. Certificate of transfer to Navy Fleet Reserve, Marine Corps Fleet
Reserve, or enlisted Reserve Corps.</p>
<p>3. Orders of Transfer to Retired List.</p>
<p>4. Report of Separation from a branch of the Armed Forces.</p>
<p>5. Certificate of Service or release from active duty, provided
honorable separation is shown.</p>
<p>6. Official Statement from a branch of the Armed Forces showing that
honorable separation took place.</p>
<p>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, that
the veteran was honorably separated from military service,</p>
<p>8. Official statement from the Military Personnel Records Center that
official service records show that honorable separation took place.</p>
</blockquote>
<p>B. DOCUMENTATION OF SERVICE-CONNECTED DISABILITY (NON COMPENSABLE,
I.E., LESS THAN 10%); PURPLE HEART; AND NONSERVICE-CONNECTED DISABILITY
PENSION</p>
<blockquote>
<p>Submit one of the following documents:</p>
<p>1. An official statement, dated within the last 12 months, from the
Department of Veterans Affairs or from a branch of the Armed Forces,
certifying to the present existence of the veteran’s service-connected
disability of less than 10%.</p>
<p>2. An official citation, document, or discharge certificate, issued
by a branch of the Armed Forces, showing the award to the veteran of the
Purple Heart for wound or injuries received in action.</p>
<p>3. An official statement, dated within the last 12 months, from the
Department of Veterans Affairs, certifying that the veteran is receiving
a nonservice-connected disability pension.</p>
</blockquote>
<p>C. DOCUMENTATION OF SERVICE-CONNECTED DISABILITY (COMPENSABLE, I.E.,
10% OR MORE)</p>
<blockquote>
<p>Submit one of the following documents, if you checked Item 11 on the
front of this form:</p>
<p>1. An official statement, dated within the last 12 months, from the
Department of Veterans Affairs or from a branch of the Armed Forces,
certifying to the veteran’s present receipt of compensation for
service-connected disability or disability retired pay.</p>
<p>2. An official statement dated within the last 12 months, from the
Department of Veterans Affairs or from a branch of the Armed Forces,
certifying that the veteran has a service-connected disability of 10% or
more.</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="4"><blockquote>
<p>3. An official statement or retirement orders from a branch of the
Armed Forces, showing that the retired serviceman was retired because of
permanent service-connected disability or was transferred to the
permanent disability retirement list. The statement or retirement orders
must indicate that the disability is 10% or more.</p>
<p>For spouses and mothers of disabled veterans checking Items 12 or 14,
submit the following:</p>
<p>An official statement, dated within the last 12 months, from the
Department of Veterans Affairs or from a branch of the Armed Forces,
certifying: 1) the present existence of the veteran's service-connected
disability, 2) the percentage and nature of the service-connected
disability or disabilities (including the combined percentage), 3) a
notation as to whether or not the veteran is currently rated as
“unemployable” due to the service-connected disability, and 4) a
notation as to whether or not the service-connected disability is rated
as permanent and total.</p>
</blockquote>
<p>D. DOCUMENTATION OF VETERAN’S DEATH</p>
<blockquote>
<p>1. 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>
<p>2. If death occurred while not on active military duty, submit death
certificate.</p>
</blockquote>
<p>E. DOCUMENTATION OF SERVICE OR DEATH DURING A WAR, IN A CAMPAIGN OR
EXPEDITION FOR WHICH A CAMPAIGN BADGE IS AUTHORIZED, OR DURING THE
PERIOD OF APRIL 28,1952 THROUGH JULY 1,1955</p>
<blockquote>
<p>Submit 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>F. DOCUMENTATION OF DECEASED OR DISABLED VETERAN’S MOTHER’S CLAIM FOR
PREFERENCE BECAUSE OF HER HUSBAND’S TOTAL AND PERMANENT DISABILITY.</p>
<blockquote>
<p>Submit a statement from husband’s physician showing the prognosis of
his disease and percentage of his disability.</p>
</blockquote>
<p>G. DOCUMENTATION OF ANNULMENT OF REMARRIAGE BY WIDOW OR WIDOWER OF
VETERAN</p>
<blockquote>
<p>Submit either:</p>
<p>1. Certification from the Department of Veterans Affairs that
entitlement to pension or compensation was restored due to
annulment.</p>
<p>2. A certified copy of the court decree of annulment.</p>
</blockquote>
<p>H. DOCUMENTATION OF VETERAN’S INABILITY TO WORK BECAUSE OF A
SERVICE-CONNECTED DISABILITY</p>
<p>Answer questions 1 - 7 below:</p></td>
</tr>
<tr class="even">
<td colspan="2">1. Is the veteran currently working?</td>
<td> YES</td>
<td colspan="3"> NO</td>
<td colspan="6">2. If currently working, what is the veteran’s present
occupation?</td>
</tr>
<tr class="odd">
<td>If “NO”, go to Item 3.</td>
<td colspan="5"></td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="6">3. What was the veteran’s occupation, if any, before
military service?</td>
<td colspan="6">4. What was the veteran’s military occupation at the
time of separation?</td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="6">     </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="3">     </td>
<td colspan="5" rowspan="3">     </td>
<td colspan="2">From</td>
<td>To</td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="2">     </td>
<td rowspan="2">     </td>
</tr>
<tr class="even">
</tr>
<tr class="odd">
<td colspan="12">6. Has the veteran resigned from, been disqualified
for, or separated from a position in the Federal civil service or
D.C.</td>
</tr>
<tr class="even">
<td colspan="9">Government along the lines of his/her usual occupation
because of service-connected disability?</td>
<td colspan="2"> YES</td>
<td> NO</td>
</tr>
<tr class="odd">
<td colspan="12">If “YES”, submit documentation of the resignation,
disqualification, or separation.</td>
</tr>
<tr class="even">
<td colspan="4">7. Is the veteran receiving a civil service retirement
pension?</td>
<td colspan="3"> YES</td>
<td colspan="5"> NO</td>
</tr>
<tr class="odd">
<td colspan="7">If “YES”, give the Civil Service or Federal Employee
retirement annuity number</td>
<td colspan="3"></td>
<td colspan="2"><strong>CSA      </strong></td>
</tr>
<tr class="even">
<td colspan="12">STANDARD FORM 15 (REV. 2/90) BACK</td>
</tr>
</tbody>
</table>