Fillable Form expires 1/31/21: VETS-1011LP HIRE Vets Medallion Award (Department of Labor)

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Form expires 1/31/21: VETS-1011LP HIRE Vets Medallion Award (Department of Labor)

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Yes:
PAGE 1
HIRE Vets Medallion Award Application
Large Employer - Platinum Award
VETS-1011LP
OMB No. 1293-0015
Form expires 1/31/21
Item 11 Medallion Level: Are you applying for the platinum level?
Yes:
Please note that this form includes accompanying instructions for the Large Employer Platinum Award that explain
how to fill out this form. These instructions include important information, such as definitions and rules, for
determining whether an employer has met the medallion criteria. You must read the instructions for the Large
Employer Platinum Award at the end of this document prior to completing and submitting the application.
SECTION A: EMPLOYER INFORMATION
Item 1 Employer Name
Enter the exact employer name assigned the
Employer Identification Number (EIN) listed in Item 2.
Item 2 Enter the employer EIN. Do not enter your SSN
on this line.
Item 3 Data Universal Number System (DUNS) Number
Enter the DUNS number if one exists.
Item 4 Employer Doing Business As (DBA) Name
If the employer utilizes a DBA, enter it here.
Item 5 Employer Street Address
Enter the official address (number, street, and
room or suite number, as applicable, of the
employer's principal office or place of business)
for the employer listed in Item 1.
Item 6 Employer City or Town
Enter the city or town.
Item 7 Employer State or Province
Enter the State or province.
Item 8 Employer ZIP Code or Postal Code
Enter the ZIP code or postal code.
Item 9 Country
Enter the country name. Please do not
abbreviate the country name.
Item 10 Employer Size: Did you have 500 or more employees as of December 31 of 2020 (the year prior to the year
in which you are submitting the application)? If the answer to this question is "No," you are submitting the wrong
form.
For the purposes of this item, "employees" includes both veteran and non-veteran employees, as well as permanent
full-time and permanent part-time employees. "Employees" does not include temporary workers. For additional
information about the definitions of employee, temporary worker, and veteran, please see the instructions.
SAMPLE ONLY
Item 14 The veteran hiring percentage in 2020 (the preceding CY) was..............................................
Item 17 The percentage of veterans retained for 12 months was........................................................
Item 16 divided by Item 15. Item 17 must be not less than 85% for the applicant to qualify for the Large
Employer Platinum Award.
VETS-1011LP
OMB No. 1293-0015
Item 16 Enter the number of veterans hired in 2019 (the CY preceding the preceding
CY) who remained with the employer for at least 12 months.
In order to qualify for the HIRE Vets Medallion Award, an applicant must satisfy all of the following criteria.
HIRING: 10% Requirement
Item 12 Enter the number of veterans hired in 2020 (the preceding calendar year (CY)).
Item 13 Enter the total number of employees (including veterans) hired in 2020 (the preceding CY).
Item 12 divided by Item 13. Item 14 must be not less than 10% for the applicant to qualify for the Large
Employer Platinum Award.
Please refer to the definitions of employee, temporary worker, and veteran in the instructions when completing
Section B.
RETENTION: 85% Requirement
Item 15 Enter the number of veterans hired in 2019 (the CY preceding the preceding CY).
SECTION B: VETERAN EMPLOYEE CRITERIA
HIRE Vets Medallion Award Application
Large Employer - Platinum Award
PAGE 2
SAMPLE ONLY
0.0%
0.0%
Item 19 Briefly describe the programs you have established to enhance the leadership skills of veteran employees
during their employment. See Item 19 in the instructions for additional guidance about leadership program
criterion requirements.
(1,000 character limit)
SECTION C: INTEGRATION ASSISTANCE CRITERIA
(1,000 character limit)
SECTION D: ADDITIONAL FORMS OF INTEGRATION ASSISTANCE
Item 20 Briefly describe your employment of dedicated human resources professionals to support hiring,
training, and retention of veteran employees. See Item 20 in the instructions for additional guidance about
dedicated human resources professional criterion requirements.
(1,000 character limit)
Item 18 Briefly describe your employee veteran organization or resource group. Your employee veteran
organization or resource group must assist new veteran employees with integration, including coaching and
mentoring. See Item 18 in the instructions for additional guidance about employee veteran organization or
resource group criterion requirements.
HIRE Vets Medallion Award Application
Large Employer - Platinum Award
PAGE 3
VETS-1011LP
OMB No. 1293-0015
SAMPLE ONLY
Item 23 (OPTIONAL) Briefly describe any employer efforts to support the veteran and military community that fall
outside of the criteria but may serve as models of support for veterans and their families. This may include efforts
such as veteran/military spouse recruitment and employment. This will not factor into whether an employer
recei
ves an
award.
(1,000 character limit)
(
1,0
00 character limit)
Item 22 Briefly describe the employer's tuition assistance program to support veteran employees' attendance in
post-secondary education during the term of their employment. See Item 22 in the instructions for additional
guidance about tuition assistance criterion requirements.
(1,000 character limit)
Item 21 Briefly describe how the employer provides each of its employees serving on active duty in the United
States National Guard or Reserve with compensation sufficient, in combination with the employee's active duty
pay, to achieve a combined level of income commensurate with the employee's salary prior to undertaking active
duty. See Item 21 in the instructions for additional guidance about pay differential criterion requirements.
HIRE Vets Medallion Award Application
Large Employer - Platinum Award
PAGE 4
VETS-1011LP
OMB No. 1293-0015
SAMPLE ONLY
Item 29 Attestation: I declare under penalty of perjury under the laws of the United States of America that:
SECTION F: ATTESTATION INFORMATION For Items 25-26, provide information for the person attesting to Item 29.
Item 25 First and Last Name:
Item 26 Title:
Item 27 Contact Email Address:
Item 28 Contact Phone Number:
Item 24 As further explained in Item 24 of the instructions, the employer has not had an adverse labor law decision,
stipulated agreement, contract debarment, or contract termination pursuant to USERRA or VEVRAA. By selecting
the "I agree" button below, you certify that the above statement is true.
SECTION E: LABOR LAW VIOLATIONS
I agree
1. I am the Chief Executive Officer or the Chief Human Relations Officer of this employer submitting this
application (hereinafter "the Employer"), or an equivalent official (someone with equivalent responsibilities and
duties, such as the owner of a small firm) of the Employer;
2. The Employer has met all necessary award criteria;
3. I have read and reviewed this application and the information contained therein is true and accurate; and
4. I understand that to knowingly furnish false information in the preparation of this form and any supplement
thereto or to aid, abet, or counsel another to do so is a violation of Federal law under 18 U.S.C. 1001.
Entering your name in Item 25 above and then clicking on the "I agree" button below constitutes your signing the
above attestation under penalty of perjury.
I agree
Item 30 Application Fee Payment: The application fee is posted at https://www.hirevets.gov. By selecting the "I
understand" button below, you acknowledge understanding that your application will not be processed until the
application fee payment is received, and that your application will not be processed if the fee is received after the
end of the application period. The application fee is to be paid via Pay.Gov.
I understand
Disclaimer: Information submitted as part of this publication may be made available to the public. Applicants should not
include any proprietary or confidential business information or personally identifiable information (PII) in this summary. In
the event that an applicant submits proprietary or confidential business information or PII, DOL is not liable for making this
information public. The submission of the application constitutes a waiver of the applicant's objection to the posting of any
proprietary or confidential business information contained in the application. Additionally, the applicant is responsible for
obtaining all authorizations from relevant parties for publishing all PII contained within the application. In the event the
application contains proprietary or confidential business information or PII, the applicant is presumed to have obtained all
necessary authorizations to provide this information and may be liable for any improper release of this information.
OMB Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB number.
Obligation to respond is required to obtain or retain benefits under the Honoring Investments in Recruiting and Employing American Military
Veterans Act. The 10.75 hour public reporting burden for this collection of information, which is to apply for an award showcasing excellence in
hiring and retaining veterans, includes time to review instructions, search existing data sources, gather and maintain the data needed, and
complete and review the collection of information. Send comments regarding this burden estimate, or any other aspect of this collection,
including suggestions for reducing burden, to the U.S. Department of Labor, Veterans' Employment and Training Service, Room S-1212, 200
Constitution Avenue, NW, Washington, DC 20210.
HIRE Vets Medallion Award Application
Large Employer - Platinum Award
PAGE 5
VETS-1011LP
OMB No. 1293-0015
SAMPLE ONLY
VETS1011-LP
Instructions
The following instructions are designed to assist in properly applying for the HIRE Vets Medallion
Award. Before an application is submitted, please ensure that:
- All information as submitted on the application form is correct.
- Every required element of the application form has been filled out.
- You have read and complied with these instructions.
For questions on completing this form, please contact hirevets.application@dol.gov. Please note that
the regulations governing the HIRE Vets Medallion Program can be found at 20 CFR part 1011.
Definitions
The following are key definitions that apply for the purpose of the HIRE Vets Medallion Program. Please
use these definitions when filling out the application for the Large Employer Platinum Award.
Employee means any individual for whom the employer furnishes an IRS Form W-2, excluding
temporary workers.
Employer means any person, institution, organization, or other entity that pays salary or wages for work
performed or that has control over employee opportunities, except for the Federal Government or any
State or foreign government. For the purposes of this regulation, VETS will recognize employers based
on the Employer Identification Number, as described in 26 CFR 301.7701-12, used to furnish an IRS
Form W-2 to an employee. However, in the case of an agent designated pursuant to 26 CFR 31.3504-1,
a payor designated pursuant to 26 CFR 31.3504-2, or a Certified Professional Employer Organization
recognized pursuant to 26 U.S.C. 7705, the employer shall be the common law employer, client, or
customer, respectively, instead of the entity that furnishes the IRS Form W-2. Consequently, in the case
where an employer uses an agent designated pursuant to 26 CFR 31.3504-1, a payor designated
pursuant to 26 CFR 31.3504-2, or a Certified Professional Employer Organization recognized pursuant to
26 U.S.C. 7705, the common law employer is the proper applicant for the award regardless of what EIN
is on employees' IRS Forms W-2.
Temporary worker means any worker hired with the intention that the worker be retained for less than
one year and who is actually retained for less than one year.
Veteran
has the meaning given such term under 38 U.S.C. 101. VETS recognizes that most employers
determine which employees are veterans according to the employee's self-identification. VETS does not
expect employer-applicants to change these practices in order to guarantee that every employee who
self-identifies as a veteran meets the definition of veteran at 38 U.S.C. 101.
Items
This section provides additional information on certain items on the application.
SECTION A: EMPLOYER INFORMATION
Item 1 – Explanation contained on form.
Item 2 – The employer must enter its EIN unless the employer uses an agent designated pursuant to 26
CFR 31.3504-1, a payor designated pursuant to 26 CFR 31.3504-2, or a Certified Professional Employer
Organization recognized pursuant to 26 U.S.C. 7705 to furnish the IRS Forms W-2 to its employees. If
you are an employer that falls under one of these exceptions, you may leave this field blank. Otherwise,
an EIN is required.
Page|6
Page|7
SECTION B: VETERAN EMPLOYEE CRITERIA
Items 12-17 – Explanation contained on form.
SECTION C: INTEGRATION ASSISTANCE CRITERIA
Item 18 – To satisfy this criterion, the employer's organization/resource group must:
• assist new veteran employees with integration, including coaching and mentoring;
• be a distinct organization or group (although admirable, an employer would not satisfy this
criterion if the employer provided coaching and mentoring to veteran employees but did so
without having established an organization or group);
• still be in existence as of December 31 of 2020 (the year prior to the calendar year in which the
employer applies for the award).
Item 19 – To satisfy this criterion, the employer's leadership program must:
• enhance the leadership skills of veteran employees during their employment;
• still be in existence as of December 31 of 2020 (the year prior to the calendar year in which the
employer applies for the award).
A leadership program does not need to be exclusively for veterans so long as veteran employees may
participate in the leadership program.
SECTION D: ADDITIONAL FORMS OF INTEGRATION ASSISTANCE
Item 20 – To satisfy this criterion, the employer's dedicated human resources professional(s) must:
• provide support in all three of the following areas: hiring, training, and retention;
• still be employed as of December 31 of 2020 (the year prior to the calendar year in which the
employer applies for the award).
Dedicated human resources professional(s) means either a full-time professional or the equivalent of a
full-time professional dedicated exclusively to supporting the hiring, training, and retention of veteran
employees. Two half-time professionals, for example, are equivalent to one full-time professional.
Additionally, three full-time employees who devote fifty percent, thirty percent, and twenty percent of
their time, respectively, to supporting the hiring, training, and retention of veteran employees would
satisfy this criterion.
Dedicated human resources professional(s) need not be employees of the applicant. An applicant can
satisfy this criterion by contracting out these services so long as those contracted services otherwise
meet this definition.
Items 3-11 – Explanation contained on form.
VETS1011-LP
Exception for large employers with 5,000 or fewer employees: Large employers who employ 5,000 or
fewer employees need not have a dedicated human resources professional to support the hiring and
retention of veteran employees. A large employer with 5,000 or fewer employees can satisfy this
criterion by employing at least one human resources professional whose regular work duties include
supporting the hiring, training, and retention of veteran employees.
Page|8 VETS1011-LP
Item 21 – To satisfy this criterion, employers must:
• provide each of its employees serving on active duty in the United States National Guard or
Reserve with compensation sufficient, in combination with the employee's active duty pay, to
achieve a combined level of income commensurate with the employee's salary prior to
undertaking active duty;
• provide the differential for as long as the employee is on active duty;
• ensure that this pay differential is still in existence as of December 31 of 2020 (the year prior to
the calendar year in which the employer applies for the award).
Active Duty means active duty as defined in 10 U.S.C. 101(d)(1).
Salary means an employee's base pay. This means that employers need not provide overtime, shift
differential, bonuses, tips, commissions, vacation and holiday pay, retirement and other related benefits,
stock options, etc., as part of their pay differential to qualify for the award. Additionally, the method for
calculating salary can be determined by the employer so long as that determination is reasonable and
applied consistently across all employees.
Item 22 – To satisfy this criterion, employers must:
• have a tuition assistance program to support veteran employees' attendance in post-secondary
education during the term of their employment;
• ensure that the tuition assistance program is still in existence as of December 31 of 2020 (the
year prior to the calendar year in which the employer applies for the award).
Post-secondary education means post-secondary level education or training courses that would be
acceptable for credit toward at least one of the following: associate's or bachelor's degree or higher,
any other recognized post-secondary credential, or an apprenticeship.
Item 23 – Explanation contained on form.
SECTION E: LABOR LAW VIOLATIONS
Item 24 – Employers cannot receive a HIRE Vets Medallion Award if they have any of the labor
law violations identified in 20 CFR § 1011.120. The applicable language at 20 CFR § 1011.120 reads as
follows:
(a) Any employer with an adverse labor law decision, stipulated agreement, contract
debarment, or contract termination, as defined in paragraphs (b) through (e) of this section,
pursuant to either of the following labor laws, as amended, will not be eligible to receive an
award:
1. Uniformed Services Employment and Reemployment Rights Act (USERRA);
2. Vietnam Era Veterans' Readjustment Assistance Act
(VEVRAA);
(b) For purposes of this application, an adverse labor law decision means any of the
following, issued in the calendar year prior to year in which applications are solicited or the
calendar year in which applications are solicited up until the issuance of the award, in which a
violation of any of the laws in paragraph (a) of this section is found:
1. a civil or criminal judgment;
Page|9
VETS1011- LP
2. a final administrative merits determination of an administrative adjudicative
board or commission; or
3. a decision of an administrative law judge or other administrative judge that is
not appealed and that becomes the final agency action.
(c) For purposes of this application, a stipulated agreement means any agreement
(including a settlement agreement, conciliation agreement, consent decree, or other similar
document) to which the employer is a party, entered into in the calendar year prior to
year in
which applications are solicited or
the
calendar year in which applications are solicited up until
the issuance of the award, that contains an admission that
the employer violated either of the
laws cited in paragraph (a) of this section.
(d) For purposes of this application, a contract debarment means any order or voluntary
agreement, pursuant to the laws listed in paragraph (a) of this section, that debars the
employer from receiving any future Federal contract. Employers
shall be ineligible for an award
for the duration of time that the contract debarment is in effect.
(e) For purposes of this application, a contract
termination means any order or voluntary
agreement, pursuant to the laws listed in paragraph (a)
of this section, that terminates an
existing Federal contract prior to its completion. Employers shall be ineligible for the award if
this termination occurred in the calendar year prior to year in which applications are solicited
or the calendar year in which applications are solicited up until the issuance of the award.
To receive a HIRE Vets Medallion Award, the employer must not have any violations identified in the
above regulatory text during the time periods identified in the regulation.
Additionally, per 20 CFR § 1011.120(f), if VETS has credible information that a significant violation of
one of the laws cited in paragraph (a) of § 1011.120 may have occurred that could lead to an employer
being disqualified pursuant to any of paragraphs (b) through (e) of § 1011.120, VETS may delay issuing
an award.
SECTION F: ATTESTATION INFORMATION
Items 25-30 – Explanation contained on form.
Disclaimer
Please note that, in addition to the guidance in this document, all HIRE Vets Medallion Awards and
applications are also subject to the HIRE Vets Medallion Program regulations at 20 CFR part 1011 and
the HIRE Vets Act. To the extent that anything in these instructions contradicts the regulations or Act,
the regulations and Act govern.
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Form expires 13121: VETS-1011LP HIRE Vets Medallion Award (Department of Labor)

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Completed 26 January 2021

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