Form 22-10201 VET TEC Employment Certification Form

OMB Approved No. 2900-XXXX
Respondent Burden: 5 Minutes
Expiration Date: XXXXXXXXXX

VET TEC EMPLOYMENT CERTIFICATION FORM
NOTE: Department of Veterans Affairs defines Meaningful Employment as:
• Traditional employment in a career supported by the completed program of study.
• Promotion in the veteran's current career if the veteran is currently employed in a career supported by the completed program of study.
• Self-employment if the veteran owns or operates a business and is utilizing the skills obtained through the completion of the program of study.
Please be prepared to provide proof of meaningful employment in the form of an offer letter, pay stub, promotion offer, note from manager, or marketing material
showing expansion in scope or level of services for veteran owned businesses.
Submit this form by email to: [email protected].
CERTIFICATION OF MEANINGFUL EMPLOYMENT (To be completed by veteran)
I HEREBY acknowledge, by my signature below, that I have accepted a job offer for meaningful employment which aligns with the skills I acquired during my
VET TEC training program, which was funded by the Department of Veterans Affairs.
2. DATE OF BIRTH

1. VETERAN'S NAME

3. EMAIL

EMPLOYMENT INFORMATION (To be completed by veteran)
4. EMPLOYER NAME AND ADDRESS

6. SUPERVISOR'S TELEPHONE
NUMBER (Include Area Code)

5. SUPERVISOR'S NAME

7. SUPERVISOR'S EMAIL

8. EMPLOYER'S WEBSITE
10. SALARY

9. JOB TITLE
11. DESCRIBE EMPLOYMENT DUTIES AND RESPONSIBILITIES

12. HOURS PER WEEK (Average) 13. HIRE DATE

15. END DATE (If contract)

14. START DATE

I CERTIFY THAT all the information I have provided is true and correct to the best of my knowledge and belief and I authorize the Department of Veterans Affairs
to verify my employment if needed. I understand that by submitting this certification, I am making a statement to the government for the purposes of obtaining federal
benefits. Section 1001 of Title 18 of the U. S. Code makes it a criminal offense for any person to knowingly and willfully make false or fraudulent statements to any
department or agency of the United States Government.
17. DATE

16. VETERAN'S SIGNATURE

CERTIFICATION OF MEANINGFUL EMPLOYMENT (To be completed by Certifying Official (CO) at Training Provider)
19. CO'S TELEPHONE NUMBER
(Include Area Code)

18. CO NAME AND TITLE

20. NAME OF TRAINING PROVIDER

21. TYPE OF PROGRAM

22. EMAIL

By signing, I CERTIFY (1) that the information provided above is true, complete and correct to the best of my knowledge and belief, and (2) that I am an
authorized official of the organization mentioned. I understand that by submitting this certification, I am making a statement to the government for the purposes of
obtaining federal benefits. Section 1001 of Title 18 of the U. S. Code makes it a criminal offense for any person to knowingly and willfully make false or fraudulent
statements to any department or agency of the United States Government.
23. CO SIGNATURE

24. DATE

PRIVACY ACT NOTICE: § 116 of Public Law 115-48 authorizes VA to implement a 5-year pilot program that proves eligible Veterans the opportunity to enroll in high technology
programs of education that provide training and skills sought by employers in relevant high technology fields or industries. Accelerated Learning Programs targeted for VET TEC are
generally less than 10 months in duration, offered by organizations which are not institutions of higher learning, and do not lead to a degree. They are designed to provide students the
requisite training in demand by employers seeking to source IT talent. VA will create this new form so that veterans may certify they have completed training and are now employed in the
high technology industry, also this form will be used to collect certain information from interested applicants to be used in VA reports to Congress that will help determine if the program
should continue. While you do not have to respond, VA cannot process your claim for education assistance unless the information is furnished as required by Public Law 115-48. The
responses you submit are considered confidential (38 U.S.C. 5701). Any information provided by applicants, recipients, and others may be subject to verification through computer
matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine your ability to participate in the VET TEC High Technology Pilot Program, 38 CFR 36.4344, Title 38, United

States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to review the instructions, find the information, and complete this form. VA
cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
VA FORM
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22-10201