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Standard Form 15 (Rev. 2/90) (EG) APPLICATION FOR 10-POINT


U.S. Office of Personnel Management VETERAN PREFERENCE
 FPM Supplement 296-33 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 

Branch of Service From To Service Number 

8. Veteran’s Social Security 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 

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 Parts211, 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. 

12.	 PREFERENCE FOR A SPOUSE of a living veteran based on the fact that the a. Are you presently married 

YES NO 

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? (Submit G when applicable.) preference and need not submit this form.) 

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 

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). 

Signature of Person Claiming Preference Date Signed 

(Month, Day, Year) 

FOR USE BY APPOINTING OFFICER ONLY 

Signature and Title of Appointing Officer 

Preference Entitlement Was Verified 

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 

HONORABLE CONDITIONS 

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: 

1. Honorable or general discharge certificate. 

2. Certificate of transfer to Navy Fleet Reserve, Marine Corps Fleet 

Reserve, or enlisted Reserve Corps. 

3. Orders of Transfer to Retired List. 

4. Report of Separation from a branch of the Armed Forces. 

5. Certificate of Service or release from active duty, provided 

honorable separation is shown. 

6. Official Statement from a branch of the Armed Forces showing 

that honorable separation took place. 

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. 

8. Official statement from the Military Personnel Records Center that 

official service records show that honorable separation took place. 

B. 	DOCUMENTATION OF SERVICE-CONNECTED DISABILITY (NONCOMPENSABLE, I.E., LESS THAN 10%); PURPLE HEART; AND 

NONSERVICE-CONNECTED DISABILITY PENSION 

Submit one of the following documents: 

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%. 

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. 

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. 

C. 	DOCUMENTATION OF SERVICE-CONNECTED DISABILITY 

(COMPENSABLE, I.E., 10% OR MORE) 

Submit one of the following documents, if you checked Item 11 on 

the front of this form: 

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. 

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. 

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. 

For spouses and mothers of disabled veterans checking Items 12 or 14, submit the following: 

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 veterans 

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 serviceconnected disability is rated as permanent and total. 

D. DOCUMENTATION OF VETERAN’S DEATH 

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. 

2. 	If death occurred while not on active military duty, submit death 

certificate. 

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 

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. 

F. 	DOCUMENTATION OF DECEASED OR DISABLED VETERAN’S 

MOTHER’S CLAIM FOR PREFERENCE BECAUSE OF HER 

HUSBAND’S TOTAL AND PERMANENT DISABILITY. 

Submit a statement from husband’s physician showing the prognosis 

of his disease and percentage of his disability. 

G. DOCUMENTATION OF ANNULMENT OF REMARRIAGE BY WIDOW 

OR WIDOWER OF VETERAN 

Submit either: 

1. 	Certification from the Department of Veterans Affairs that 

entitlement to pension or compensation was restored due to 

annulment. 

2. A certified copy of the court decree of annulment. 

H. 	DOCUMENTATION OF VETERAN’S INABILITY TO WORK BECAUSE 

OF A SERVICE-CONNECTED DISABILITY 

Answer questions 1 - 7 below: 

1. Is the veteran currently working? 

If "NO", go to Item 3. 

YES NO 2. If currently working, what is the veteran’s present occupation? 

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. of Employment 

From To 

Dates 

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. 

If "YES", give the Civil Service or Federal Employee retirement annuity number 

7. Is the veteran receiving a civil service retirement pension? YES NO 

CSA 

STANDARD FORM 15 (REV. 2/90) BACK