Form VA Form 22-10201 VA Form 22-10201 Employment Certification Form

OMB Approved No. 2900-0874
Respondent Burden: 5 Minutes
Expiration Date: 12/31/2022

EMPLOYMENT CERTIFICATION FORM
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 either my Veteran Employment through Technology Education Courses (VET TEC) or my Veteran Rapid Retraining Assistance
Program (VRRAP) which was funded by the Department of Veterans Affairs.
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.
VET TEC Participants: Submit this form by email to: [email protected].
VRRAP Participants: Submit this form by email to: VBAMUS/RO/EDU/[email protected].

SECTION I - CERTIFICATION OF MEANINGFUL EMPLOYMENT (To be completed by veteran)
PROGRAM SELECTION - Please select the program that you would like to certify employment for by checking the appropriate "Yes" box below:
Veteran Employment Through Technology Education Courses (VET TEC):

YES

1. VETERAN'S NAME

2. DATE OF BIRTH

Veteran Rapid Retraining Assistance Program (VRRAP):

YES

3. EMAIL

SECTION II - EMPLOYMENT INFORMATION (To be completed by veteran)
4. EMPLOYER NAME

5. EMPLOYER ADDRESS
Number & Street:
City, State & ZIP Code:

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

6. SUPERVISOR'S NAME

8. SUPERVISOR'S EMAIL

9. EMPLOYER'S WEBSITE

10. JOB TITLE

11. SALARY

12. DESCRIBE HOW YOUR NEW DUTIES AND RESPONSIBILITIES ALIGN WITH YOUR FIELD OF STUDY

13. HOURS PER WEEK (Average) 14. HIRE DATE

16. END DATE (If contract)

15. 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.
18. DATE

17. VETERAN'S SIGNATURE

SECTION III - CERTIFICATION OF MEANINGFUL EMPLOYMENT (To be completed by Certifying Official (CO))
20. CERTIFYING OFFICIAL'S TELEPHONE
NUMBER

19. CERTIFYING OFFICIAL'S NAME AND TITLE

21. NAME OF TRAINING PROVIDER

22. TYPE OF PROGRAM

23. 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.
25. DATE

24. CERTIFYING OFFICIAL'S SIGNATURE

VA FORM
XXX XXXX

22-10201

SUPERSEDES VA FORM 22-10201, DEC 2019,
WHICH WILL NOT BE USED.

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PRIVACY ACT NOTICE: Section 8006 of Public Law 117-2, and Section 116 of Public Law 115-48 authorized VA to implement the Veteran
Rapid Retraining Assistance Program (VRRAP), and the Veteran Employment through Technology Education Courses (VET TEC) programs,
respectively. Both of these programs provide assistance to an eligible veteran for the pursuit of a covered program of education. This form therefore
allows veterans who either participated in a VRRAP or VET TEC program to certify to VA that they have found employment in a field related to
their program of education. Also, this form is used to collect certain information from the applicant to be used in VA reports to Congress that
will assist with outcome measures. While you do not have to respond, VA cannot process your claim for education assistance unless the
information is furnished as required by Section 8006 of Public Law 117-2 or Section 116 of 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 with other agencies.
RESPONDENT BURDEN: We need this information to determine your ability to participate in either the VRRAP or VET TEC Program.
Section 8006 of Public Law 117-2 and Section 116 of Public Law 115-48 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 22-10201, XXX XXXX

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