VETS-1011SG HIRE Vets Medallion Award Application Small Employer - G

VETS-1011SG
OMB No. XXX-XXX
Form Expires:
Please note that this form includes accompanying instructions for the Small Employer Gold Award that explain
how to fill out this form. These instructions include important information, such as definitions and rules for
determining whether an employer has met the medallion criteria. You must read the instructions for the Small
Employer Gold Award at the end of this document prior to completing and submitting the application.
HIRE Vets Medallion Award Application
Small Employer - Gold Award

PAGE 1

SECTION A: EMPLOYER INFORMATION
Item 1 Employer Name
Enter the exact employer name assigned the
Employer Identification Number (EIN) listed in item 2.
Item 2 Enter the employer EIN. Do not enter your
SSN on this line.
Item 3 Data Universal Number System (DUNS) number
Enter the DUNS number if one exists.
Item 4 Employer Doing Business As (DBA)
name If the employer utilizes a DBA, enter it
here.
Item 5 Employer Street Address
Enter the official address (number, street, room or
suite number, of the employer's principle office or
place of business) for the employer listed in Item 1.
Item 6 Employer City or Town
Enter the city or town.
Item 7 Employer State or Province
Enter the state or province.
Item 8 Employer Zip Code or Postal Code
Enter the zip code or postal code.
Item 9 Country
Enter country name.
Please do not abbreviate the country name
Item 10 Employer Size: Did you have 50 or less employees as of December 31 of the year prior to the year
in which you are submitting the application? Example, if applying for the 2019 award, you must have had 50
or less employees on December 31, 2018. If the answer to this question is "no" you are submitting the
wrong form.
For the purposes of this item, "employees" includes both veteran and non-veteran employees, as well as
permanent full-time and permanent part-time employees. "Employees" does not include temporary
workers. For additional information about the definition of employee, temporary worker, and veteran please
see the instructions. Yes:

Item 11

Medallion Level: Confirm you are applying for the Gold level.

Yes:

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HIRE Vets Medallion Award Application
Small Employer - Gold Award

VETS-1011SG
OMB No. XXX-XXX

SECTION B: VETERAN EMPLOYEE CRITERIA
Please refer to the definitions of employee, temporary worker, and veteran in the instructions when
completing Section B.
HIRING: 7% Requirement
Item 12 Enter the number of veterans hired in the preceding calendar year (CY).

Example, if applying for the 2019 award, enter the number of veterans hired during the 2018 CY.

Item 13 Enter the total number of employees (including veterans) hired in the preceding CY.
Item 14 The The veteran hiring percentage in the preceding CY was.................................................
Item 12 divided by Item 13. Item 14 must be not less than 7% for the applicant to qualify
for the Small Employer Gold Award.

0.0%

OR
RETENTION: 75% Requirement
Item 15 Enter the number of veterans hired in the CY preceding the preceding CY.
Example, if applying for the 2019 award, enter the number of veterans hired during the 2017 CY.

Item 16 Enter the number of veterans hired in the CY preceding the preceding CY who
remained with the employer for at least 12 months.
Example, if applying for the 2019 award, enter the number of veteran employees hired in 2017
who were retained for at least 12 months from the date of hire.

Item 17 The percentage of veterans retained for 12 months was...................................................
Item 16 divided by Item 15. Item 17 must be not less than 75% for the applicant
to qualify for the Small Employer Gold Award.

0.0%

AND
VETERAN EMPLOYEE PERCENTAGE: 7% Requirement
Item 18 Enter the total number of veterans employed on December 31st of the preceding
CY. Example, if applying for the 2019 award, enter the number of veteran employees as of December
31, 2018.

Item 19 Enter the total number of employees (including veterans) with the company on
December 31st of the preceding CY.

Example, if applying for the 2019 award, enter the total number of employees as of December 31,
2018.

Item 20 The proportion of veteran employees...............................................
Item 18 divided by Item 19. Item 20 must be not less than 7% for the applicant to qualify
for the Small Employer Gold Award.

0.0%

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HIRE Vets Medallion Award Application
Small Employer - Gold Award

VETS-1011SG
OMB No. XXX-XXX

Item 21 OPTIONAL: Briefly describe any employer efforts to support the veteran and military
community that fall outside of the criteria but may serve as models of support for veterans and their
families. This may include efforts such as veteran/military spouse recruitment and employment.
This will not factor into whether an employer receives an award.
(1,000 character limit)

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VETS-1011SG
OMB No. XXX-XXX

HIRE Vets Medallion Award Application
Small Employer - Gold Award

SECTION C: LABOR LAW VIOLATIONS
Item 22:
As further explained in in Item 24 of the instructions, the employer has not had an adverse labor law decision,
stipulated agreement, contract debarment, or contract termination pursuant to USERRA or VEVRAA. By
selecting the "I Agree" button below, you certify that the above statement is true.
SECTION D: ATTESTATION INFORMATION For Items 23-24,

I Agree

provide information for the person attesting to Item 27.

Item 23 Name:
Item 24 Title:
Item 25 Contact email address:
Item 26 Contact phone number:

Item 27 Attestation:
I declare under penalty of perjury under the laws of the United States of America that:
1) I am the Chief Executive Officer or the Chief Human Relations Officer of this employer submitting this application
(hereinafter “the Employer”), or an equivalent official (someone with equivalent responsibilities and duties, such as
the owner of a small firm) of the Employer;
2) The Employer has met all necessary award criteria;
3) I have read and reviewed this application and the information contained therein is true and accurate; and
4) I understand that to knowingly furnish false information in the preparation of this form and any supplement
thereto or to aid, abet, or counsel another to do so is a violation of federal law under 18 U.S.C. 1001.
Clicking on the "I Agree" button below, constitutes your making the above attestation under penalty of perjury.
I Agree
Item 28 Application Fee Payment:
The application fee is posted at www.dol.gov/vets/hirevets/. Use the following Pay.Gov link to submit
payment, https://www.pay.gov/public/form/start/XXXXXXXX. By selecting the "I Understand" button below,
you acknowledge understanding that your application will not be processed until the application fee
payment is received, and that your application will not be processed if the fee is received after the end of
the application period.
I Understand
Disclaimer: Information submitted as part of this publication may be made available to the public. Applicants should not include
any proprietary or confidential business information or personally identifiable information (PII) in this summary. In the event
that an applicant submits proprietary or confidential business information or PII, DOL is not liable for making this information
public. The submission of the application constitutes a waiver of the applicant’s objection to the posting of any proprietary or
confidential business information contained in the application. Additionally, the applicant is responsible for obtaining all
authorizations from relevant parties for publishing all PII contained within the application. In the event the application contains
proprietary or confidential business information or PII, the applicant is presumed to have obtained all necessary authorizations
to provide this information and may be liable for any improper release of this information.
OMB Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB number.
Obligation to respond is required to obtain or retain benefits under the Honoring Investments in Recruiting and Employing American Military
Veterans Act). The 5.25 hour public reporting burden for this collection of information, which is to apply for an award showcasing excellence
in hiring and retaining veterans, includes time to review instructions, search existing data sources, gather and maintain the data needed, and
complete and review the collection of information. Send comments regarding this burden estimate, or any other aspect of this collection,
including suggestions for reducing burden, to the U.S. Department of Labor, Veterans' Employment and Training Service, Room S-1212, 200
Constitution Avenue, NW, Washington, DC 20210.

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Instructions

VETS1011-SG

The following instructions are designed to assist in properly applying for the HIRE Vets Medallion Award.
Before an application is submitted, please ensure that:
-

The employer did not receive an award in the previous calendar year. Employers who
received an Award in the previous calendar year are not eligible for an Award.
All information is submitted on the application form is correct.
Every required element of the application form has been filled out.
You have read and complied with these instructions.

For questions on completing this form, please contact: ([email protected]). Please note that
the regulations governing the HIRE Vets Medallion Award Program can be found at 20 CFR part 1011.

Definitions
The following are key definitions that apply for the purpose of the HIRE Vets Medallion Award Program.
Please use these definitions when filling out the application for the Small Employer Gold Award.
Employee means any individual for whom the employer furnishes an IRS Form W-2, excluding temporary
workers.
Employer means any person, institution, organization, or other entity that pays salary or wages for work
performed or that has control over employee opportunities, except for the Federal Government or any
State or foreign government. For the purposes of this regulation, VETS will recognize employers based
on the Employer Identification Number, as described in 26 CFR 301.7701-12, used to furnish an IRS Form
W-2 to an employee. However, in the case of an agent designated pursuant to 26 CFR 31.3504-1, a
payor designated pursuant to 26 CFR 31.3504-2, or a Certified Professional Employer Organization
recognized pursuant to 26 U.S.C. 7705, the employer shall be the common law employer, client, or
customer, respectively, instead of the entity that furnishes the IRS Form W-2. Consequently, in the case
where an employer uses an agent designated pursuant to 26 CFR 31.3504-1, a payor designated
pursuant to 26 CFR 31.3504-2, or a Certified Professional Employer Organization recognized pursuant to
26 U.S.C. 7705, the common law employer is the proper applicant for the Award regardless of what EIN
is on employees’ IRS Form W-2s.
Temporary Worker means any worker hired with the intention that the worker be retained for less than
one year and who is actually retained for less than one year.
Veteran has the meaning given such term under 38 U.S.C. 101. VETS recognizes that most employers
determine which employees are veterans according to the employee’s self-identification. VETS does not
expect employer-applicants to change these practices in order to guarantee that every employee who
self-identifies as a veteran meets the definition of veteran at 38 U.S.C. 101.

Items
This section provides additional information on certain items on the application.
SECTION A: EMPLOYER INFORMATION
Items 1-9 - Explanation contained on form

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VETS1011-SG

Item 10 - Select the choice that corresponds to the number of total employees as of 31 December for
the year prior to the year in which you are filling out the application. The number of employees includes
both veteran and non-veteran, permanent full-time and permanent part-time employees. However, as
described in the definition of employee, temporary workers must not include temporary workers.
Item 11 - Explanation contained on form
SECTION B: VETERAN EMPLOYEE CRITERIA
Items 12-21 – Explanation contained on form
SECTION C: LABOR LAW VIOLATIONS
Item 22 - Employers cannot receive a HIRE Vets Medallion Award if they have any of the labor law
violations identified in 20 CFR 1011.120. The applicable language at 20 CFR 1011.120 reads as follows:
(a)
Any employer with an adverse labor law decision, stipulated agreement, contract
debarment, or contract termination, as defined in paragraphs (b) through (e), pursuant to
either of the following labor laws, as amended, will not be eligible to receive an Award:
1.

Uniform Services Employment and Reemployment Rights Act (USERRA);

2.

Vietnam Era Veterans' Readjustment Assistance Act (VEVRAA);

(b)
For purposes of this application, an adverse labor law decision means any of the
following, issued in the calendar year prior to year in which applications are solicited or the
calendar year in which applications are solicited up until the issuance of the Award, in which a
violation of any of the laws in paragraph (a) is found:
1.

a civil or criminal judgment;

2.
a final administrative merits determination of an administrative adjudicative
board or commission; or
3.
a decision of an administrative law judge or other administrative judge that is
not appealed and that becomes the final agency action.
(c)
For purposes of this application, a stipulated agreement means any agreement
(including a settlement agreement, conciliation agreement, consent decree, or other similar
document) to which the employer is a party, entered into in the calendar year prior to year in
which applications are solicited or the calendar year in which applications are solicited up until
the issuance of the Award, that contains an admission that the employer violated any of the
laws in paragraph (a).
(d)
For purposes of this application, a contract debarment means any order or voluntary
agreement, pursuant to the laws listed in paragraph (a), which debars the employer from
receiving any future federal contract. Employers shall be ineligible for an Award for the duration
of time that the contract debarment is in effect.

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VETS1011-SG

(e)
For purposes of this application, a contract termination means any order or voluntary
agreement, pursuant to the laws listed in paragraph (a), which terminates an existing federal
contract prior to its completion. Employers shall be ineligible for the award if this termination
occurred in the calendar year prior to year in which applications are solicited or the calendar
year in which applications are solicited up until the issuance of the Award.
To receive a HIRE Vets Medallion Award, the employer must not have any violations identified in the
above regulatory text during the time periods identified in the regulation.
Additionally, per 20 CFR 1011.120(f), if VETS has credible information that a significant violation of one
of the laws in paragraph (a) may have occurred that could lead to an employer being disqualified
pursuant to any of paragraphs (b) through (e) of this section, VETS may delay issuing an Award.
SECTION D: ATTESTATION INFORMATION
Items 23-28 – Explanation contained on form

Disclaimer
Please note that, in addition to the guidance in this document, all HIRE Vets Medallion Awards and
applications are also subject to the HIRE Vets regulations at 20 CFR part 1011 and the HIRE Vets Act. To
the extent that anything in these instructions contradict the regulations or Act, the regulations and Act
govern.