VA Form 22-10201 Employment Certification Form

OMB Approved No. 2900-0874
Respondent Burden: 5 Minutes
Expiration Date: XX/XX/XXXX

EMPLOYMENT CERTIFICATION
PART I - CERTIFICATION OF EMPLOYMENT (To be completed by veteran)

IMPORTANT - Please be prepared to provide proof of employment in the form of an offer letter, pay stub, promotion offer,
note from manager, or marketing material showing expansion in scope of level of services for veteran owned businesses.
Where to send completed form:
VET TEC Participants: Submit this form by email to: [email protected].
VRRAP Participants: Submit this form by email to: [email protected].
SECTION I - APPLICANT INFORMATION
1A. VETERAN'S NAME (First, Middle Initial, Last)

1B. DATE OF BIRTH

1C. EMAIL

SECTION II - PROGRAM SELECTION AND EMPLOYMENT (To be completed by veteran)
2. PLEASE SELECT THE PROGRAM THAT YOU WOULD LIKE TO CERTIFY EMPLOYMENT FOR BY CHECKING THE APPROPRIATE "YES"
BOX BELOW:
YES

VETERAN EMPLOYMENT THROUGH TECHNOLOGY EDUCATION COURSES (VET TEC) (If checked complete Item 3A)

YES

VETERAN RAPID RETRAINING ASSISTANCE PROGRAM (VRRAP) (If checked complete Item 3B)

NOTE - IF ACTIVELY SEEKING EMPLOYMENT BUT HAVE NOT FOUND EMPLOYMENT, PLEASE WAIT AT LEAST 180 DAYS TO
COMPLETE THIS FORM.
3. PLEASE PROVIDE YOUR EMPLOYMENT STATUS AFTER PROGRAM COMPLETION, WITHDRAWAL, OR TERMINATION IN ITEM 3A OR 3B.

3B. VRRAP PARTICIPANTS
COMPLETE ITEMS BELOW:

3A. VET TEC PARTICIPANTS
COMPLETE ITEMS BELOW:
VET TEC PARTICIPANTS ONLY: I HEREBY acknowledge, by
my signature in Item 14, that I am/have: (Check all that apply)

VRRAP PARTICIPANTS ONLY: I HEREBY acknowledge, by
my signature in Item 14, that I am/have: (Check all that apply)

Unemployed or did not find meaningful employment, within 180 days after
my program

Unemployed or did not find employment in a field related to the program of
education, within 180 days after my program

Continuing education - I enrolled in a different program of education to
continue my educational pursuits

Continuing education - I enrolled in a different program of education to
continue my educational pursuits

Found meaningful employment, which aligns with the skills I acquired during
my VET TEC program. Select the type of employment found by checking the
appropriate box below:

Found employment, in a field related to my program of education in the
Veteran Rapid Retraining Assistance Program. Select the type of
employment found by checking the appropriate box below:

Full-time, Part-time, or Temporary employment

Full-time, Part-time, or Temporary employment

Paid Internships, Paid Apprenticeships, or Contract employment

Paid Internships, Paid Apprenticeships, or Contract employment

Self-employed or started a new business

Self-employed or started a new business

Attained a recognized postsecondary credential during the 12-month period
after exiting the program (a credential consisting of an industry-recognized
certificate or certification, a certificate of completion of an apprenticeship, or
license recognized by the State involved or Federal Government, or an
associate or baccalaureate degree)

Attained a recognized postsecondary credential during the 12-month period
after exiting the program (a credential consisting of an industry-recognized
certificate or certification, a certificate of completion of an apprenticeship, or
license recognized by the State involved or Federal Government, or an
associate or baccalaureate degree)

NOTE: Department of Veterans Affairs defines Meaningful
Employment for VET TEC 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.
VA FORM
XXX XXXX

22-10201

SUPERSEDES VA FORM 22-10201, JUN 2021,
WHICH WILL NOT BE USED.

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PART II - EMPLOYMENT INFORMATION
SECTION I - EMPLOYER'S INFORMATION (To be completed by veteran)
2. EMPLOYER'S ADDRESS

1. EMPLOYER'S NAME

Number & Street:
City, State & ZIP Code:

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

3. SUPERVISOR'S NAME

5. SUPERVISOR'S EMAIL

6. EMPLOYER'S WEBSITE

8. SALARY

7. JOB TITLE

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

10. HOURS PER WEEK (Average) 11. HIRE DATE

13. END DATE (If contract)

12. 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.
14. VETERAN'S SIGNATURE

15. DATE

SECTION II - CERTIFICATION OF EMPLOYMENT (To be completed by Certifying Official (CO))
17. CERTIFYING OFFICIAL'S TELEPHONE NUMBER
(Include Area Code)

16. CERTIFYING OFFICIAL'S NAME AND TITLE

18. NAME OF TRAINING PROVIDER

19. TYPE OF PROGRAM

20. 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.
21. CERTIFYING OFFICIAL'S SIGNATURE

22. DATE

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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