VA Form 22-0994 Application for Veteran Employment through Technology Ed

OMB Control No. 2900-0866
Respondent Burden: 10 Minutes
Expiration Date: XXX XXXX

APPLICATION FOR VETERAN EMPLOYMENT THROUGH TECHNOLOGY EDUCATION COURSES (VET TEC)
HIGH TECHNOLOGY PROGRAM
PART I - APPLICANT INFORMATION
IMPORTANT: Please type or print. Must be legible. Demographic (prepopulated): Verify and update
1. Veteran/ServiceMember Name (First, Middle, Last)

2. Social Security Number

3. Current Mailing Address (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

4. Sex of Applicant
Male

Female

5. Date of Birth (MM/DD/YYYY)

6. E-mail Address
7A. DayTime Telephone Number (Include area code)

7B. Evening Telephone Number (Include area code)

8. Are You Currently on Active Duty or Do You Anticipate You Will Go On
Active Duty During the VET TEC Program?

9. Are You Currently on Active Duty or Do You Anticipate You Will Go On Active Duty
During the VET TEC Program?

Yes

Yes

No

No

10. DIRECT DEPOSIT INFORMATION:
The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. Please attach a voided personal check or deposit slip or
provide the information requested below to enroll in direct deposit. If you do not have a bank account, you must receive your payment through Direct Express Debit MasterCard. To request a
Direct Express Debit MasterCard you must apply at www.usdirectexpress.com or by telephone at 1-800-333-1795. If you elect not to enroll, you must contact representatives handling waiver
requests for the Department of Treasury at 1-888-224-2950. They will encourage your participation in EFT and address any questions or concerns you may have.
Routing or Transit Number (nine digits found at the lower left corner of your check):
Account Type (Check one box):

Checking

Account Number

Savings

PART II - COURSE OF STUDY
1. Select the VET TEC Program and Provider You Wish to Attend (Choose up to 3)
NAME:
_________________________________________________

NAME:
_________________________________________________

NAME:
_________________________________________________

NAME:
_________________________________________________

2. Location of Where You Plan to or Will Take Training (City, State)

3. Date You Plan to Start or Will Start Training (MM/DD/YYYY)

PART III - BACKGROUND INFORMATION
1. Are You Currently Employed? (If "No", Skip to Item 4)

Yes

2. Are You Currently Working in the high technology industry?

Yes, Select the Area

No
Computer
Programming
Data
Processing

Computer
Software
Information
Sciences

Media
Application

No
<$20,000

3. What is Your Current Salary Range?

$50,001-$75,000

$20,001-$35,000

$35,001-$50,000

>$75,000

4. What is Your Highest Level of Education? (High School, Bachelors, etc.)

VA FORM
XXX XXXX

22-0994

VA FORM 22-0994, APR 2019,
WHICH WILL NOT BE USED.

1 of 2

PART IV - CERTIFICATION AND SIGNATURE
CERTIFICATION STATEMENT:
THE INFORMATION PROVIDED ON THIS APPLICATION WILL BE USED FOR THE PURPOSES OF
DETERMINING YOUR ELIGIBILITY TO PARTICIPATE IN THE VETERAN EMPLOYMENT THROUGH
TECHNOLOGY EDUCATION COURSES (VET TEC) HIGH TECHNOLOGY PROGRAM FROM THE
DEPARTMENT OF VETERANS AFFAIRS. THE INFORMATION MAY BE AUDITED FOR ACCURACY. BY
SIGNING BELOW, YOU AGREE TO THE FOLLOWING STATEMENT:
"I CERTIFY THAT the statements on this application, to the best of my knowledge are true and correct. I
understand that by submitting this application, 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. Additionally, I
understand that if the information I have provided on this application is found to be false or incorrect, I will immediately
be unable to receive benefits under this program, and I may be required to reimburse the federal government for any
benefits I have already received."

14. Signature of Applicant

15. DATE SIGNED

RESPONDENT BURDEN: We need this information to determine your ability to participate in the VET TEC High Technology Pilot Program, 38
U.S.C. 3702 (d) and 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 10 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.
PRIVACE ACT NOTICE: This form under § 116 of Public Law 115-48 authorizes VA to implement a 5-year pilot program that provides 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. The responses you submit are considered confidential (38 U.S.C. 5701). VA may disclose the information that you
provide, including Social Security numbers, outside VA if the disclosure is authorized under the Privacy Act, including the routine uses identified in
the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA,
published in the Federal Register. The requested information is considered relevant and necessary to determine maximum benefits under the law.
Your obligation to respond is required in order to obtain or retain education benefits. Giving us your SSN account information is voluntary. Refusal
to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her
SSN unless the disclosure of the SSN is required by Federal Statute of law enacted before January 1, 1975 and still in effect. Any information
provided by applicants may be subject to verification through computer matching programs with other agencies.

VA FORM 22-0994, XXX XXXX

2 of 2