VETS-1011MP HIRE Vets Application Medium Employer Platinum (Screensh

Honoring Investments in Recruiting and Employing American Veterans Medallion Program

HIRE Vets Application Medium Employer Platinum (Screenshot) VETS-1011MP

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⚠️ Notice: This form may be outdated.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:

2024-03-27 - Extension without change of a currently approved collection

Document [pdf]

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United States Department of Labor

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FAQ

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

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

Medium Employer, Platinum Medallion

Instructions

B. Veteran Employee Criteria

C. Integration Assistance Criteria

D. Additional Forms of
Integration Assistance

Employer Identity

Employer Address

Employer Size

Please note that this form includes accompanying instructions for the Medium Employer Platinum 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
Medium Employer Platinum Award prior to completing and submitting the application.
1
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 8.25 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.

E. Labor Law Violations

F. Review and Attestation

G. Pay Application Fee

If you need assistance please see our FAQ page.

CONTINUE

Questions?
If you need to find answers
and general information
quickly about the HIRE Vets
Medallion Application, please
review the FAQ Page. 3

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

•
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

Accessibility Statement

United States Department of Labor

! Contact

ABOUT

Sections

NEWS

RESOURCES

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

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

Medium Employer, Platinum Medallion

B. Veteran Employee Criteria

Instructions

Employer Address

Employer Identity

Employer Size

Item 1 Employer Name (*Required)
C. Integration Assistance Criteria

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

D. Additional Forms of
Integration Assistance

Item 2 Enter the employer EIN

E. Labor Law Violations

Do not enter your SSN on this line.

Item 3 Data Universal Number System (DUNS) Number

F. Review and Attestation

7
G. Pay Application Fee

Enter the DUNS number if one exists.

Item 4 Employer Doing Business As (DBA) Name

Questions?
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and general information
quickly about the HIRE Vets
Medallion Application, please
review the FAQ Page.

If the employer utilizes a DBA, enter it here.

BACK

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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

NEWS

RESOURCES

FAQ

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

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

Medium Employer, Platinum Medallion

Instructions

B. Veteran Employee Criteria

Employer Identity

Employer Address

Employer Size

Item 5 Employer Street Address (*Required)
C. Integration Assistance Criteria

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. Additional Forms of
Integration Assistance

Item 6 Employer City or Town (*Required)

E. Labor Law Violations
Enter the city or town.
F. Review and Attestation
Item 7 Employer State or Province
(*Required)

G. Pay Application Fee

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.

Questions?

Item 9 Country (*Required)

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

UNITED STATES

Select the Country.

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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

NEWS

RESOURCES

FAQ

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

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

Medium Employer, Platinum Medallion

Instructions

B. Veteran Employee Criteria

C. Integration Assistance Criteria

D. Additional Forms of
Integration Assistance

Employer Identity

Employer Address

Employer Size

Item 10 Employer Size: Did you have 51 to 499 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

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)

E. Labor Law Violations
Yes

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

F. Review and Attestation
Item 11 Medallion Level: Are you applying for the platinum level? (*Required)
Yes

G. Pay Application Fee

17 If No, return to your Dashboard, delete this application and begin a new one for the correct level

BACK

Questions?

SAVE AND CONTINUE

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

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

NEWS

RESOURCES

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

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT $

FAQ

Medium Employer, Platinum Medallion

Criteria

B. Veteran Employee Criteria

C. Integration Assistance Criteria

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

D. Additional Forms of
Integration Assistance

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

E. Labor Law Violations

HIRING: 10% Requirement

F. Review and Attestation

G. Pay Application Fee

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…

Questions?

Item 12 divided by Item 13. Item 14 must be not less than 10% for the applicant to qualify
for the Medium Employer Platinum Award.

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

0.0%

RETENTION: 85% 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.

0.0%

Item 17 The percentage of veterans retained for 12 months was...
Item 16 divided by Item 15. Item 17 must be not less than 85% for the applicant to
qualify for the Medium Employer Platinum Award.

AND

VETERAN EMPLOYEE PERCENTAGE: 10% 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...

0.0%

Item 18 divided by Item 19. Item 20 must be not less than 10% for the applicant to
qualify for the Medium Employer Platinum Award.

BACK

SAVE AND CONTINUE

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

NEWS

RESOURCES

FAQ

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

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

Medium Employer, Platinum Medallion

Employee Veteran Organization or Resource Group

B. Veteran Employee Criteria

C. Integration Assistance Criteria

Leadership Program

# 25

Item 21 Briefly describe your employee veteran organization or resource group. Your employee
veteran organization or resource group must assist new veteran employees with integration,
including coaching and mentoring. See Item 21 in the instructions for additional guidance about
employee veteran organization or resource group criterion requirements (*Required)

D. Additional Forms of
Integration Assistance

E. Labor Law Violations

F. Review and Attestation
(1,000 character limit)
G. Pay Application Fee

BACK

SAVE AND CONTINUE

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

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

NEWS

RESOURCES

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

FAQ

MY ACCOUNT "

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

Medium Employer, Platinum Medallion

Employee Veteran Organization or Resource Group

B. Veteran Employee Criteria

C. Integration Assistance Criteria

Leadership Program

Item 22 Briefly describe the programs you have established to enhance the leadership skills of
veteran employees during their employment. See Item 22 in the instructions for additional guidance
about leadership program criterion requirements. (*Required)

# 27

D. Additional Forms of
Integration Assistance

E. Labor Law Violations

F. Review and Attestation

(1,000 character limit)

G. Pay Application Fee

BACK

SAVE AND CONTINUE

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

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

NEWS

RESOURCES

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

FAQ

MY ACCOUNT "

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

Medium Employer, Platinum Medallion

Employer Programs

B. Veteran Employee Criteria

C. Integration Assistance Criteria

Community

In order to qualify for the Medium Employer Platinum Award, an applicant must satisfy only ONE of the
following three criteria (Item 23, 24, or 25). Only fill out ONE of the items 23, 24, or 25. (*Required) 50
Item 23 Briefly describe the human resources veterans’ initiative you have established. See Item
23 in the instructions for additional guidance about human resources veterans' initiative criterion
requirements.

D. Additional Forms of
Integration Assistance

$ 44

E. Labor Law Violations

F. Review and Attestation

G. Pay Application Fee
(1,000 character limit)
Item 24 Briefly describe how the employer provides each of its employees serving on active duty in
the United States National Guard or Reserve with compensation sufficient, in combination with the
employee’s active duty pay, to achieve a combined level of income commensurate with the
employee’s salary prior to undertaking active duty. See Item 24 in the instructions for additional
guidance about pay differential criterion requirements.

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

(1,000 character limit)
Item 25 Briefly describe the employer's tuition assistance program to support veteran employees’
attendance in post-secondary education during the term of their employment. See Item 25 in the
instructions for additional guidance about tuition assistance criterion requirements.

(1,000 character limit)

BACK

SAVE AND CONTINUE

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

NEWS

RESOURCES

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

FAQ

MY ACCOUNT "

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

Medium Employer, Platinum Medallion

Employer Programs

B. Veteran Employee Criteria

C. Integration Assistance Criteria

Community

Item 26 (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.

D. Additional Forms of
Integration Assistance

E. Labor Law Violations

F. Review and Attestation
(1,000 character limit)
G. Pay Application Fee

BACK

SAVE AND CONTINUE

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

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

NEWS

RESOURCES

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

FAQ

MY ACCOUNT "

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

Medium Employer, Platinum Medallion

Labor Law Violations

B. Veteran Employee Criteria

C. Integration Assistance Criteria

Item 27 As further explained in Item 27 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)

D. Additional Forms of
Integration Assistance

I agree

BACK

E. Labor Law Violations

SAVE AND CONTINUE

F. Review and Attestation

G. Pay Application Fee

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

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

NEWS

RESOURCES

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

Return to Dashboard

2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

Medium Employer, Platinum Medallion

Review and Attestation

B. Veteran Employee Criteria

Review
C. Integration Assistance Criteria

D. Additional Forms of
Integration Assistance

Please review the information below to ensure it is accurate.

A. Employer Information
Item 1

Employer Name

Item 2

Employer EIN

##-#######

Item 3

Data Universal Number System (DUNS) Number

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

Item 4

Employer Doing Business As (DBA) Name

N/A

Item 5

Employer Street Address

Item 6

Employer City or Town

Questions?

Item 7

Employer State or Province

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

Item 8

Employer ZIP Code or Postal Code

#####

Item 9

Country

E. Labor Law Violations

F. Review and Attestation

G. Pay Application Fee

Item 10 Employer Size

Yes - Medium

Item 11 Medallion Level: Platinum

Yes - Platinum

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…

########

C. Integration Assistance Criteria
Item 21 Briefly describe your employee veteran
organization or resource group. Your employee
veteran organization or resource group must
assist new veteran employees with integration,
including coaching and mentoring. See item 21 in
the instructions for additional guidance about
employee veteran organization or resource
group criterion requirements

Lorem ipsum dolor sit amet, consectetur
adipiscing elit. Quisque ullamcorper
viverra aliquet.

Item 22 Briefly describe the programs you have
established to enhance the leadership skills of
veteran employees during their employment.
See Item 22 in the instructions for additional
guidance about leadership program criterion
requirements.

Lorem ipsum dolor sit amet, consectetur
adipiscing elit. Quisque ullamcorper
viverra aliquet.

D. Additional Forms of Integration Assistance

Item 23 Briefly describe the human resources veterans’
initiative you have established. See Item
23 in the instructions for additional guidance
about human resources veterans' initiative
requirements.

Lorem ipsum dolor sit amet, consectetur
adipiscing elit. Quisque ullamcorper
viverra aliquet.

Item 24 Briefly describe how the employer provides
each of its employees serving on active duty in
the United States National Guard or Reserve
with compensation sufficient, in combination
with the employee’s active duty pay, to achieve a
combined level of income commensurate with
the employee’s salary prior to undertaking
active duty. See Item 24 in the instructions for
additional guidance about pay differential
criterion requirements.

Lorem ipsum dolor sit amet, consectetur
adipiscing elit. Quisque ullamcorper
viverra aliquet. Lorem ipsum dolor sit
amet, consectetur adipiscing elit.
Quisque ullamcorper viverra aliquet.

Item 25 Briefly describe the employer's tuition
assistance program to support veteran
employees’ attendance in post-secondary
education during the term of their employment.
See Item 25 in the instructions for additional
guidance about tuition assistance criterion
requirements.

Lorem ipsum dolor sit amet, consectetur 59
adipiscing elit. Quisque ullamcorper
viverra aliquet.

E. Labor Law Violations
Item 27 As further explained in Item 27 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 28-29, provide information for the person attesting to Item 32.
Item 28 First and Last Name (*Required)
37

Item 29 Title (*Required)
38

54 55

Select the relevant title for the person attesting to Item 32.
Item 30 Contact Email Address (*Required)

39
Item 31 Contact Phone Number (*Required)
40

Item 32 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 28 above and then clicking on the “I agree” button below constitutes your
signing the above attestation under penalty of perjury.
41

I agree

Item 33 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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Department of Labor

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LABOR DEPARTMENT

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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

NEWS

RESOURCES

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

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2019 HIRE Vets Application

A. Employer Information

MY ACCOUNT "

FAQ

Medium Employer, Platinum Medallion

B. Veteran Employee Criteria

$ Your application has been submitted.
C. Integration Assistance Criteria

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

D. Additional Forms of
Integration Assistance

% Note: Payment must be submitted by April 30th and completed no later than May 31st

E. Labor Law Violations

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.

F. Review and Attestation

G. Pay Application Fee

I am making the payment

Someone else is making the payment

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

United States
Department of Labor

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LABOR DEPARTMENT

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200 Constitution Ave. NW

White House

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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

United States Department of Labor

! Contact

ABOUT

NEWS

RESOURCES

FAQ

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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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

NEWS

RESOURCES

FAQ

MY ACCOUNT "

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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

$190 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.

United States
Department of Labor

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Submit
PAYMENT

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FEDERAL GOVERNMENT

LABOR DEPARTMENT

ABOUT THE SITE

200 Constitution Ave. NW

White House

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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

NEWS

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)

$190 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

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

NEWS

RESOURCES

FAQ

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
$190 US

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MAKEtoPAYMENT
Dashboard

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

NEWS

RESOURCES

FAQ

MY ACCOUNT "

Return to Dashboard

Payment Status

% Print

# Your Plastic Card Payment was successful

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
Plastic Card
Payment Details
Name:
Business Name:
Account Number:
Payment Amount:

Joe Example
Sample, Inc
XXXXX1234
$190 US

Return
MAKEtoPAYMENT
Dashboard

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

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