VETS-1011SG HIRE Vets Application Small Employer Gold (Screenshot)

Honoring Investments in Recruiting and Employing American Veterans Medallion Program

HIRE Vets Application Small Employer Gold (Screenshot) VETS-1011SG

HIRE Vets Medallion Program

OMB: 1293-0015

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1293-0015 can be found here:

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OMB No. (1293-0015)
Form expires: 1/31/21

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2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

Small Employer, Gold Medallion

Instructions

B. Veteran Employee Criteria

Employer Identity

Employer Address

Employer Size

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 prior to completing and submitting the application.
1

C. Labor Law Violations

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 5.75 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.

D. Review and Attestation

E. Pay.gov Information

Questions?
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quickly about the HIRE Vets
Medallion Application, please
review the FAQ Page. 3

If you need assistance please see our FAQ page.

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•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
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•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
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•
10% of new hires are veterans
• DOL
85%Newsletter
of veterans were retained
Subscribe to the
Disclaimers
•
The employer must have all of the following Veteran
Integration Assistance Programs: Important Web Site Notices
Read The DOL Newsletter
⁃
Veteran Organization or Resource Group
⁃
Leadership Program
Emergency Accountability Status Link
Plug-ins Used by DOL
⁃
Human Resource Veterans Initiative
⁃
Pay Differential Program
A to Z Index
RSS Feeds from DOL
⁃
Tuition Assistance

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OMB No. (1293-0015)
Form expires: 1/31/21

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

Small Employer, Gold Medallion

B. Veteran Employee Criteria

Instructions

Employer Address

Employer Identity

Employer Size

Item 1 Employer Name (*Required)
C. Labor Law Violations

5
Enter the exact employer name assigned the Employer Identification Number (EIN) listed in Item 2.

D. Review and Attestation
Item 2 Enter the employer EIN

E. Pay.gov Information

Do not enter your SSN on this line.

Item 3 Data Universal Number System (DUNS) Number

Questions?

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Medallion Application, please
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Enter the DUNS number if one exists.

Item 4 Employer Doing Business As (DBA) Name

If the employer utilizes a DBA, enter it here.

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1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

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OMB No. (1293-0015)
Form expires: 1/31/21

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

Small Employer, Gold Medallion

Instructions

B. Veteran Employee Criteria

Employer Identity

Employer Address

Employer Size

Item 5 Employer Street Address (*Required)
C. Labor Law Violations

8
Enter the official address (number, street, and room or suite number, as applicable, of the
employer's principal office or place of business) for the employer listed in Item 1.

D. Review and Attestation

Item 6 Employer City or Town (*Required)
E. Pay.gov Information

9
Enter the city or town.

Questions?

Item 7 Employer State or Province
(*Required)

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Medallion Application, please
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SELECT ONE

Item 8 ZIP Code or Postal Code
(*Required)

$ 10
12

Enter the State or province.

11
Enter the ZIP code or postal code.

46
Item 9 Country (*Required)

UNITED STATES

Select the Country.

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1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

www.dol.gov

Recovery Act
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Accessibility Statement

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OMB No. (1293-0015)
Form expires: 1/31/21

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

Small Employer, Gold Medallion

Instructions

B. Veteran Employee Criteria

Employer Identity

Employer Address

Employer Size

Item 10 Employer Size: Did you have 50 or less employees as of December 31 of 2018 (the year
prior to the year in which you are submitting the application)? If the answer to this question is
“No" you are submitting the wrong form.

C. Labor Law Violations

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 definitions of employee,
temporary worker, and veteran, please see the instructions. (*Required)

D. Review and Attestation

E. Pay.gov Information

Yes 16 If No, return to your Dashboard, delete this application and begin a new one for the correct size

Questions?

Item 11 Medallion Level: Are you applying for the gold level? (*Required)
Yes 17 If No, return to your Dashboard, delete this application and begin a new one for the correct level

If you need to find answers
and general information
quickly about the HIRE Vets
Medallion Application, please
review the FAQ Page.

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Department of Labor

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FEDERAL GOVERNMENT

LABOR DEPARTMENT

ABOUT THE SITE

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White House

Español

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Washington DC 20210

Affordable Care Act

Office of Inspector General

Privacy & Security Statement

1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

www.dol.gov

Recovery Act
No Fear Act
U.S. Office of Special Counsel

Accessibility Statement

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ABOUT

Sections

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OMB No. (1293-0015)
Form expires: 1/31/21

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT $

FAQ

Small Employer, Gold Medallion

B. Veteran Employee Criteria

Criteria

Community

Please refer to the definitions of employee, temporary worker, and veteran in the
instructions when completing Section B.

C. Labor Law Violations

To qualify for the Small Employer Gold Award, the employer must fill out and satisfy
either the hiring requirement OR the retention AND employee veteran percentage
requirementsas well as all the other criteria. (*Required) 49

D. Review and Attestation

HIRING: 7% Requirement

E. Pay.gov Information

Item 12 Enter the number of veterans hired in 2018 (the preceding calendar year (CY)).

Item 13 Enter the total number of employees (including veterans) hired in 2018
(the preceding CY).

Questions?
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and general information
quickly about the HIRE Vets
Medallion Application, please
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Item 14 The veteran hiring percentage in 2018 (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%

RETENTION: 75% Requirement
Item 15 Enter the number of veterans hired in 2017 (the CY preceding the preceding CY).

Item 16 Enter the number of veterans hired in 2017 (the CY preceding the
preceding CY) who remained with the employer for at least 12 months.

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 2018 (the
preceding CY).

Item 19 Enter the total number of employees (including veterans) with the
company on December 31st of 2018 (the preceding CY).

Item 20 The proportion of veteran employees is...
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.

BACK

0.0%

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1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

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2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

OMB No. (1293-0015)
Form expires: 1/31/21

Small Employer, Gold Medallion

B. Veteran Employee Criteria

Criteria

Community

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.

C. Labor Law Violations

D. Review and Attestation

E. Pay.gov Information

Questions?

(1,000 character limit)

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and general information
quickly about the HIRE Vets
Medallion Application, please
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Department of Labor

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LABOR DEPARTMENT

ABOUT THE SITE

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Washington DC 20210

Affordable Care Act

Office of Inspector General

Privacy & Security Statement

1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

www.dol.gov

Recovery Act
No Fear Act
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Accessibility Statement

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Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

OMB No. (1293-0015)
Form expires: 1/31/21

Small Employer, Gold Medallion

Labor Law Violations

B. Veteran Employee Criteria

Item 22 As further explained in Item 22 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. (*Required)

C. Labor Law Violations

I agree 36

D. Review and Attestation

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E. Pay.gov Information

SAVE AND CONTINUE

Questions?
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and general information
quickly about the HIRE Vets
Medallion Application, please
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United States
Department of Labor

Engage

FEDERAL GOVERNMENT

LABOR DEPARTMENT

ABOUT THE SITE

200 Constitution Ave. NW

White House

Español

Freedom of Information Act

Washington DC 20210

Affordable Care Act

Office of Inspector General

Privacy & Security Statement

1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

www.dol.gov

Recovery Act
No Fear Act
U.S. Office of Special Counsel

Accessibility Statement

United States Department of Labor

! Contact

ABOUT

Sections

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OMB No. (1293-0015)
Form expires: 1/31/21

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

Small Employer, Gold Medallion

Review and Attestation

B. Veteran Employee Criteria

Review
C. Labor Law Violations

Please review the information below to ensure it is accurate.

A. Employer Information

D. Review and Attestation

Item 1

Employer Name

Item 2

Employer EIN

##-#######

Item 3

Data Universal Number System (DUNS) Number

###############

Questions?

Item 4

Employer Doing Business As (DBA) Name

N/A

If you need to find answers
and general information
quickly about the HIRE Vets
Medallion Application, please
review the FAQ Page.

Item 5

Employer Street Address

Item 6

Employer City or Town

Item 7

Employer State or Province

Item 8

Employer ZIP Code or Postal Code

#####

Item 9

Country

E. Pay.gov Information

Item 10 Employer Size

Yes - Small

Item 11 Medallion Level: Platinum

Yes - Gold

B. Veteran Employee Criteria
Item 12 Enter the number of veterans hired in 2018 (the
preceding calendar year (CY)).

########

Item 13 Enter the total number of employees (including
veterans) hired in 2018 (the preceding CY).

########

Item 14 The veteran hiring percentage in 2018 (the
preceding CY) was…

########

D. Labor Law Violations
Item 22 As further explained in Item 22 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.

I agree

Attestation Information
For Items 23-24, provide information for the person attesting to Item 27.
Item 23 First and Last Name (*Required)
37

Item 24 Title (*Required)
38

54 55

Select the relevant title for the person attesting to Item 27.
Item 25 Contact Email Address (*Required)

Item 26 Contact Phone Number (*Required)
40

Item 27 Attestation (*Required)
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.
Entering your name in Item 23 above and then clicking on the “I agree” button below constitutes your
signing the above attestation under penalty of perjury.
I agree

Item 28 Application Fee Payment (*Required)
The application fee is posted at https://www.hirevets.gov. 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.

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1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

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Recovery Act
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OMB No. (1293-0015)
Form expires: 1/31/21

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

Small Employer, Gold Medallion

B. Veteran Employee Criteria

$ Your application has been submitted.
C. Labor Law Violations

Pay Application Fee
The application fee for your application must be paid before it can be processed by VETS.

D. Review and Attestation
% Note: Payment must be submitted by April 30th and completed no later than May 31st
E. Pay.gov Information

Identify Payment Maker

Identify whether you or another individual from your organization will be making the application fee payment
for your organization’s HIRE Vets Medallion Program Award Application.

Questions?
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and general information
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Medallion Application, please
review the FAQ Page.

I am making the payment

Someone else is making the payment

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1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

www.dol.gov

Recovery Act
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MY ACCOUNT "

Make Payment
Pay Application Fee on Pay.gov

Not paying on Pay.gov?

If someone else from your organization will be making the Application Fee
payment on Pay.gov, please provide them with the following link and
Application ID so that they can make the application fee payment:

Enter your Application ID
here on the Pay.gov form

Application ID: ##-####-##########
Payment URL: https://www.pay.gov/addurlhere
You can copy and paste your Application ID directly from this page to the
Payment Form in Pay.gov.
Note that it may take up to 1-3 business days for your payment to be reflected
on your HIRE Vets Medallion Application dashboard

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Privacy & Security Statement

1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

www.dol.gov

Recovery Act
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RESOURCES

FAQ

MY ACCOUNT "

Return to Dashboard

Make Payment
We use industry-standard encryption to protect the confidentiality of your personal information.
Your payment will be submitted through Pay.gov, a U.S. Government payment service.
86

Select Payment Method
xxxx-xxxx-xxxx-xxxx

XXXX

XX/XX/XX

Account Holder Name

Credit Card / Debit Card

Direct Debit / ACH Debit

Enter Payment Details
Payment Information
Application Fee

Payer Information
This information is about the individual making the payment

$90 USD

First Name (*Required)
Account Type (*Required)

Middle
71

Business Checking

Last Name (*Required)

Select the Account Type
72

Business Name (*Required)
68

Employer Name (*Required)
73

Account Number (*Required) #

Payer Email (*Required)
74

69
Routing Number (*Required) #

Payer Phone (*Required)
70
65

# Note: Payments may take 1-3 business days to process before your updated payment status is reflected on your
Hirevets.gov dashboard
I understand that I am authorizing a charge to the above account for this Application Fee, which covers
the cost of processing my application and is non-refundable.

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Submit
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Privacy & Security Statement

1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

www.dol.gov

Recovery Act
No Fear Act
U.S. Office of Special Counsel

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RESOURCES

FAQ

MY ACCOUNT "

Return to Dashboard

Make Payment
We use industry-standard encryption to protect the confidentiality of your personal information.
Your payment will be submitted through Pay.gov, a U.S. Government payment service.
86

Select Payment Method
xxxx-xxxx-xxxx-xxxx

XXXX

XX/XX/XX

Account Holder Name

Credit Card / Debit Card

Direct Debit / ACH Debit

Enter Payment Details
Payment Information

Payer Information

Application Fee

First Name (*Required)

$90 USD

Card Type (*Required)
Business

Middle

Personal

Last Name (*Required)

Account Holder Name (*Required)

72
83

Employer Name (*Required)
73

Account Number (*Required) #
69
Card Security Code (*Required) #

Payer Email (*Required)
74

Payer Phone (*Required)

Note: if your card does not have a security code, Contact Us

Card Expiration (*Required)
Month

Year

Select Month

Select Year

I understand that I am authorizing a charge to the above account for this Application Fee, which covers
the cost of processing my application and is non-refundable.

MAKE
Submit
PAYMENT

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Privacy & Security Statement

1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

www.dol.gov

Recovery Act
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MY ACCOUNT "

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Payment Status

% Print

# Your Direct Debit / ACH Payment was received and will soon be processed
Note: Payments may take 1-3 business days to process before your updated payment status is reflected on your Hirevets.gov dashboard

Payment Summary
Payment Information
Confirmation Number
paygov_tracking_id

& COPY

Payer Information
Payer Name:
Employer Name:
Payer Email:
Payer Phone:

Joe Example
Sample, Inc
[email protected]
123-456-7890

Payment Method
Direct Debit / ACH Debit
Payment Details
Account Type:
Business Name:
Account Number:
Payment Amount:

Business Checking
Sample, Inc
XXXXX1234
$90 US

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FEDERAL GOVERNMENT

LABOR DEPARTMENT

ABOUT THE SITE

200 Constitution Ave. NW

White House

Español

Freedom of Information Act

Washington DC 20210

Affordable Care Act

Office of Inspector General

Privacy & Security Statement

1-866-4-USA-DOL
1-866-487-2365

•

7% of new hires are veterans AND 75% of
veterans
were retained
Disaster
Recovery
Assistance
•
The employer must have BOTH a Veteran
Organization or Resources Group AND A
USA.gov
Leadership Program

TTY

Plain Writing Act

www.dol.gov

Recovery Act
No Fear Act
U.S. Office of Special Counsel

Accessibility Statement

File Type	application/pdf
File Modified	2018-11-27
File Created	2018-11-27