Form VETS Form 1010 VETS Form 1010 USERRA/VP/VEOA Claim Form

0MB NO. 1293-0002 (EXP. 04/30/2026)
VETS USERRANPNEOA FORM 1010 (REV 04/2023)
Before you submit a USERRA or Veterans' Preference claim to VETS, please be sure you are familiar with the laws and procedures that apply to these types of claims. If you need more information about
USERRA or Veterans' Preference before submitting your claim, please go to the VETS "elaws" sites: the USERRA Advisor and/or the Veterans' Preference Advisor

Section H. Claimant Demographic Information
1.Do you have a non-service-connected disability?@

OYes

0 No

2. Date of Birth

3. Ethnicity

mmlddlyyyY

4. Race (Select all that apply)@

D American Indian or Alaskan Native

□ Asian

D Black or African American

D Native Hawaiian or Other Pacific Islander

□ White

Dother
5. Sex (Select One that Applies) @

D Female

□ Male

I

CANCEL

11

PREVIOUS

I

-_,,,

10

0MB NO. 1293-0002 (EXP. 04/30/2026)
VETS USERRA/VPNEOA FORM 1010 (REV 0412023)

Before you submit a USERRA or Veterans' Preference claim to VETS, please be sure you are familiar with the laws and proce:-.......,.:,.QCIO