Form 26-6681 Application for Fee or Roster Personnel Designation

OMB Control No. 2900-0113
Respondent Burden: 30 Minutes
Expiration Date: XXXXXXXX

APPLICATION FOR FEE OR ROSTER
PERSONNEL DESIGNATION

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
Title 38, Code of Federal Regulations 1.576 for routine uses (for example: Authorized for release of information to Congress when requested for statistical purposes) as
identified in the VA system of records, (17VA26), Loan Guaranty Fee Personnel and Program Participant Records-VA, published in the Federal Register. Your obligation
to respond is mandatory. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Chapter 37, Title 38 U.S.C. VA will
not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1,
1975, and still in effect.
RESPONDENT BURDEN: We need this information to enable VA to determine whether you qualify for designation in the position for which you are applying. Title 38,
United States Code, allows us to ask for this information. We estimate that you will need an average of 30 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.

PENALTY: Failure to provide any of the requested information could affect the decision to approve your application since this decision will be made
only on the basis of available information we currently have on record. This may result in a delay in the processing of your application.
INSTRUCTIONS: Please print clearly. Completed VA application may be submitted by e-mail or by mail to the VA Regional Loan Center of Jurisdiction.
ETHNICITY AND RACE: Please provide both ethnicity and race. For race, you may check more than one designation.

DESIGNATION BEING APPLIED FOR:

REAL ESTATE APPRAISER

1. NAME OF APPLICANT (First, middle, last)

COMPLIANCE INSPECTOR

2. DATE OF BIRTH

3. SOCIAL SECURITY NUMBER

5. ETHNICITY AND RACE (Voluntary information)

4. SEX (Voluntary information)

A. ETHNICITY

B. RACE

MALE

HISPANIC OR LATINO

AMERICAN INDIAN OR ALASKAN NATIVE

FEMALE

NOT HISPANIC OR LATINO

ASIAN
BLACK OR AFRICAN AMERICAN

6. RESIDENCE ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

NATIVE HAWAIIAN OR OTHER
PACIFIC ISLANDER
WHITE

7. TELEPHONE NUMBER (Include Area Code)
8. E-MAIL ADDRESS
10. BUSINESS TELEPHONE NUMBER (Include Area Code)

9. BUSINESS ADDRESS (Address where Field Reviews are to be sent)

11. E-MAIL ADDRESS
12. PRESENT OCCUPATION

ITEM
A
B

EDUCATION
HIGH SCHOOL
COLLEGE

13. NAME AND ADDRESS OF PRESENT EMPLOYER

14. EDUCATION INFORMATION
NUMBER OF YEARS
DEGREE(S) AWARDED (If applicable)

15. ADVANCED EDUCATION OR TRAINING, VOCATIONAL, BUSINESS, OR SPECIAL COURSES (Enter course and school name and location)

16. PROFESSIONAL ORGANIZATIONS OF WHICH YOU
ARE A MEMBER

17. CERTIFICATION/LICENSE INFORMATION
(Attach copy(ies) of applicable certification/license (s))
A. KIND

18A. HAVE YOU BEEN PREVIOUSLY APPROVED BY
VA FOR A FEE POSITION?

YES
VA FORM
XXXX

NO

B. CERTIFICATION/
LICENSE NUMBER

18B. OFFICE NAME AND ADDRESS

SUPERSEDES VA FORM 26-6681, SEP 2018,
WHICH WILL NOT BE USED.

D. EXP. DATE

18C. DATES OF FEE ACTIVITY
FOR VA
FROM

(If "Yes," complete Items 18B and 18C)

26-6681

C. STATE
WHERE
ISSUED

TO

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19. GEOGRAPHIC AREA(S) OF PRACTICE (List your appraisal/inspection area(s), by State and County)

20. STATE PRINCIPAL ASSIGNMENTS DURING AT LEAST THE PAST 5 YEARS (Attach additional sheet as necessary)
A. PERIOD DATES

FROM

B. NUMBER OF
ASSIGNMENTS

TO

C. NAMES OF CLIENTS OR ORGANIZATIONS

21. EMPLOYMENT HISTORY DURING THE PAST 10 YEARS (Attach additional sheet as necessary)

A. DATES
FROM

B. OCCUPATION

TO

C. NAME OF EMPLOYER

D. ADDRESS

22. REFERENCES - LIST AND SUBMIT AT LEAST 3 LETTERS ATTESTING TO YOUR QUALIFICATIONS

(Two references must be from Fee Appraisers)

A. REFERENCES

23. NUMBER OF ASSIGNMENTS YOU WILL
ACCEPT PER WEEK

B. OCCUPATION

24. MAXIMUM NUMBER OF ASSIGNMENTS YOU
WILL ACCEPT AT ONE TIME

C. ADDRESS

25. E-MAIL ADDRESS

I, the undersigned, understand and agree that:
(a) VA may obtain a copy of my credit report.
(b) The approval of this application does not constitute my appointment as an agent or employee of the Department of Veterans Affairs.
(c) In performing fee work my status is that of an independent contractor.
(d) My sole interest in all transactions shall be to perform fee assignments as required by VA standards and criteria.

CERTIFICATION
I HEREBY CERTIFY THAT to the best of my knowledge all the information stated herein, as well as any information provided in the
accompaniment herewith, is true, accurate, and complete.
26. APPLICANT'S SIGNATURE (DO NOT PRINT) (Must be legible)

27. DATE SIGNED

REVIEWING OFFICIAL (Complete the following items)
THIS APPLICATION HAS BEEN REVIEWED AND I HEREBY RECOMMEND:

DESIGNATION

DISAPPROVAL

SIGNATURE OF REVIEWING OFFICER

VA FORM 26-6681, XXXX

THIS APPLICANT IS BEING RECOMMENDED IN THE
APPRAISAL AREA(S) OF THE COUNTY(IES) OR STATE
LISTED BELOW:

DATE OF ACTION

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