OMB NO. 1293-0002 (EXP 04/30/2010)
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
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: _______________________
6. Email Address_______________________________________ |
Section II: Uniformed Service Information
7. Serve(d) In: О Army О Navy О Marine Corps О Air Force О Coast Guard О National Guard О Reserve О Public Health Service О Other (Explain in “Comments”) О None (Retaliation Claim – Explain in “Comments”)
8. If Reserve/National Guard:
9. Dates of Service (If applicable): (a) From: ________________ To: _______________
OR (b) Date of Examination/Rejection for Service: ________________
10. Type of Discharge or Separation: О Honorable Conditions О Entry Level О Uncharacterized О Medical О Other than Honorable Conditions О Other (Explain in “Comments”) О Not Applicable |
Section III: Employer Information
11. Employer or Prospective Employer’s Name: _______________________________________________________________________
12. Address: __________________________________________________________________________________________________________ Street City County State ZIP
13. Principal Employer Contact (PEC): (a) PEC Name/Title: ___________________________________________ (b) PEC Phone: __________________________________________
14. Employment Dates (If applicable): From: ____________________ To: ____________________
15. Since beginning work with this employer, has your cumulative uniformed service exceeded 5 years? О Yes О No If YES, explain in Comments box at end of this claim form.
16. Name of Union(s) That Represent You: ______________________________________________________ |
Section IV: Claim Information
17. Was the Employer Support of the Guard and Reserve (ESGR) involved in handling your claim initially? О Yes О No
If Claim Concerns Veterans’ Preference in Federal Employment
18. Preference Issue (Check One): О Hiring О Reduction-in-Force (RIF)
If Claim Concerns Employment Discrimination under USERRA
19. Employment Discrimination Issue(s): О Hiring О Reemployment О Promotion О Termination О Benefits of Employment
If Claim Concerns Hiring, Promotion, RIF or Termination
20. Title of Position Held or Applied For: _____________________________________________________________
21. Pay Rate: __________________________
22. Date of Application Employment/Promotion: ________________________ 20a. Vacancy Announcement No.: ______________________________________________________________________
20b. Date Vacancy Opened: __________________________ 20c. Date Vacancy Closed: _________________________
If Claim Concerns Reemployment Following Service
23. Was Prior Notice of Service Provided to Employer? О Yes О No (If “No,” Explain in Comments)
24. (a) Who Provided Notice of Service to Employer? О Self О Other (name): _______________________________________
(b) Was the Notice of Service: О Written О Oral О Both
(c) Date Notice of Service was given to Employer: _______________________
25. Name/Title of Person to Whom Notice of Service was Provided: _________________________________________
26. Date Applied for Reemployment: ______________________ OR Date Returned to Work: ______________________
27. Reemployment Application Made To: Name: _________________________________ Title: _____________________________
28. Reemployed or Reinstated? О Yes (date): ______________________ О 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. I further authorize my employer or any other person to release such information to the U.S. Department of Labor. Pursuant to 5 U.S.C., Section 552a(b) of the Privacy Act, I authorize the U.S. Department of Labor and the U.S. Department of Defense to release information and 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.
For claims arising under USERRA, a person has a right to commence an action for relief directly against the employer in the appropriate federal district court (in the case of a complaint against a State or private employer), pursuant to 38 U.S.C. § 4323(a)(2), or the Merit Systems Protection Board (in the case of a complaint against a Federal executive agency or the Office of Personnel Management), pursuant to 38 U.S.C. § 4324(b).
The primary use of this information is by staff of the Veterans’ Employment and Training Service in investigating cases under USERRA or laws/regulations relating to veterans’ preference in Federal employment. Disclosure of this information may be made to: a Federal, state or local agency for appropriate reasons; in connection with litigation; and to an individual or contractor performing a Federal function. Furnishing the information on this form, including your Social Security Number, is voluntary. However, failure to provide this information may jeopardize the Department of Labor’s ability to provide assistance on your claim.
Continue in Comments box &/or use additional sheet(s) to explain items if needed – Sign and date form (above)
OMB NO. 1293-0002 (EXP 03/31/2007)
VETS/USERRA/VP Form 1010 (REV 2/99) – Page 2
Comments: _____________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ |
OMB NO. 1293-0002 (EXP 03/31/2007)
VETS/USERRA/VP Form 1010 (REV 2/99) – Page 3
| File Type | application/msword |
| File Title | OMB NO |
| Author | harvey-patrick |
| Last Modified By | mills-ira |
| File Modified | 2007-04-24 |
| File Created | 2007-04-24 |