VETERAN SELF-IDENTIFICATION FORM FOR EMPLOYMENT APPLICANTS
Protected Veteran.
Definition
This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the
Jobs for Veterans Act of 2002, 38 U. S. C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and
advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and
(4) Armed Forces service medal veterans. These classifications are defined as follows:
A “disabled veteran" is one of the following:
-A veteran of the U.S. military ground, naval or air service who is entitled to compensation (or who, but for the receipt of military
retired pay, would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
-A person who was discharged or released from active duty because of a service connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or
release from active duty in the U.S. military ground, naval or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U. S. military ground, naval, or air
service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by
the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U. S. Military ground, naval, or air
service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive
Order 12985.
Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In
particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be
reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service.
For more information, call the U. S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-
DOL.
If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box
below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach
and positive recruitment efforts we undertake pursuant to VEVRAA.
Job/Position Number
Applicant's Name (Last, First, Middle Initial)
Self Identification
Disabled veteran
Recently separated veteran
Active wartime or campaign badge veteran
Armed forces service medal veteran
Date of discharge
I identify as one or more of the classifications of protected veteran listed
I am a protected veteran, but I choose not to self-identify the classification to which I belong
I am not a protected veteran
I am not a veteran
mm/dd/yyyy
Revised
