3215 Application of Service Representative for Placement on M

OMB Approved No. 2900-0028
Respondent Burden: 10 minutes
Expiration Date: XX-XX-XXXX

APPLICATION OF SERVICE REPRESENTATIVE
FOR PLACEMENT ON MAILING LIST

RESPONDENT BURDEN: Under 38 U.S.C. 5904, the Secretary of Veterans Affairs may recognize representatives of service organizations in the preparation, presentation and
prosecution of claims under the laws administered by the Department of Veterans Affairs (VA). This form is used to process a request from a service organization to be placed on the
mailing list for specific VA publications and to assist VA regional offices in forwarding publications to service organizations to be used in rendering services and representing veterans,
their spouses and dependents.
VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB Control Number. Responding to this
collection of information is voluntary. However, if the information is not furnished, we may not be able to comply with your request. Public reporting burden for this collection of
information is estimated to average 10 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 of any other aspect of this collection of information, including suggestions
for reducing this burden, to VA Clearance Officer (005G2), 810 Vermont Avenue, NW, Washington, DC 20420. SEND COMMENTS ONLY. PLEASE DO NOT SEND
APPLICATIONS FOR BENEFITS TO THIS ADDRESS.

SECTION I
(To be completed by the applicant, a representative of a recognized organization. PLEASE KEY-STROKE DATA OR PRINT CLEARLY.)
NAME, TITLE, AND COMPELTE MAILING ADDRESS OF APPLICANT
(Exactly as they should appear on mailing labels. Be sure to include ZIP Code.)

NAME OF RECOGNIZED ORGANIZATION

APPLICANT DUTIES (Check only appropriate items.)

(X)

REVIEW OR PRESENTATION OF CLAIMS BEFORE VA
EMPLOYED IN AN OFFICIAL CAPACITY WHICH NECESSITATES USE OF
VA PUBLICATIONS
EMPLOYED FULL TIME BY THE ABOVE ORGANIZATION, FURNISHING
ASSISTANCE AND ADVICE TO VETERANS AND THEIR DEPENDENTS IN
THE PREPARATION AND DEVELOPMENT OF CLAIMS
PUBLICATIONS REQUIRED (List by specific identification, if known, or by general subject matter.)

I agree that the publications furnished by VA will be surrendered to my successor or to the issuing VA installation when my duties no
longer require their use.
SIGNATURE OF APPLICANT

DATE

SECTION II
(To be executed and forwarded in original only to VA installation (Regional Office activity) authorized to maintain a mailing list for
representatives of recognized organizations.)

I CERTIFY THAT the above-named representative's duties necessitate the use of VA publications.
SIGNATURE AND TITLE OF CERTIFYING OFFICER

DATE

SECTION III
(To be executed by VA installation Director and retained in file.)

This application for placement on the VA mailing list is approved in accordance with applicable VA directive.
SIGNATURE OF DIRECTOR

VA FORM
MAY 2002 (RS)

3215

DATE

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