Fill - Free fillable Form expires 1/31/21: VETS-1011SP HIRE Vets Medallion Award (Department of Labor) PDF form

Yes:

PAGE 1

HIRE Vets Medallion Award Application

Small Employer - Platinum Award

VETS-1011SP

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 Small 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 Small

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 50 or fewer 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 Small

Employer Platinum Award.

VETS-1011SP

OMB No. 1293-0015

Item 12 divided by Item 13. Item 14 must be not less than 10% for the applicant to qualify for the Small

Employer Platinum Award.

Please refer to the definitions of employee, temporary worker, and veteran in the instructions when completing

Section B.

To qualify for the Small Employer Platinum Award, the employer must fill out and satisfy either the hiring

requirement or the retention and veteran employee percentage requirements.

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).

SECTION B: VETERAN EMPLOYEE CRITERIA

RETENTION: 85% Requirement

Item 15 Enter the number of veterans hired in 2019 (the CY preceding the preceding CY).

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.

Item 20 The proportion of veteran employees is.................................................................................

Item 18 divided by Item 19. Item 20 must be not less than 10% for the applicant to qualify for the Small

Employer Platinum Award.

AND

VETERAN EMPLOYEE PERCENTAGE: 10% Requirement

Item 18 Enter the total number of veterans employed on December 31 of 2020 (the preceding CY).

Item 19 Enter the total number of employees (including veterans) with the company

on December 31 of 2020 (the preceding CY).

HIRE Vets Medallion Award Application

Small Employer - Platinum Award

PAGE 2

SAMPLE ONLY

0.0%

Item 22 Briefly describe the programs you have established to enhance the leadership skills of veteran employees

during their employment. See Item 22 in the instructions for additional guidance about leadership program

criterion requirements.

(1,000 character limit)

Item 23 Briefly describe the human resources veterans' initiative you have established. See Item 23 in the

instructions for additional guidance about human resources veterans' initiative criterion requirements.

(1,000 character limit)

SECTION C: INTEGRATION ASSISTANCE CRITERIA

In order to qualify for the Small Employer Platinum Award, an applicant must satisfy only TWO of the following

five criteria (Items 21-25). Only fill out TWO of the items.

Item 21 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 21 in the instructions for additional guidance about employee veteran organization or

resource group criterion requirements.

HIRE Vets Medallion Award Application

Small Employer - Platinum Award

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VETS-1011SP

OMB No. 1293-0015

SAMPLE ONLY

Item 26 (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 25 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 25 in the instructions for additional

guidance about tuition assistance criterion requirements.

(1,000 character limit)

Item 24 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 24 in the instructions for additional guidance about pay differential criterion requirements.

HIRE Vets Medallion Award Application

Small Employer - Platinum Award

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VETS-1011SP

OMB No. 1293-0015

SAMPLE ONLY

SECTION D: LABOR LAW VIOLATIONS

Item 27 As further explained in Item 27 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.

I agree

SECTION E: ATTESTATION INFORMATION For Items 28-29, provide information for the person attesting to Ite

m 32.

Item 28 First and Last Name:

Item 29 Title:

Item 30 Contact Email Address:

Item 31 Contact Phone Number:

Item 32 Attestation: I declare under penalty of perjury under the laws of the United States of America that:

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 28 above and then clicking on the "I agree" button below constitutes your signing the

above attestation under penalty of perjury.

I agree

Item 33 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 5.75 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

Small Employer - Platinum Award

PAGE 5

VETS-1011SP

OMB No. 1293-0015

SAMPLE ONLY

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VETS1011-SP

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 Small 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.

• 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 22 – 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.

Item 23 – To satisfy this criterion, the employer's human resources veterans' initiative must:

• provide support in all three of the following areas: hiring, training, and retention;

• 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).

Items 3-11 – Explanation contained on form.

SECTION B: VETERAN EMPLOYEE CRITERIA

Items 12-20 – Explanation contained on form.

SECTION C: INTEGRATION ASSISTANCE CRITERIA

In order to qualify for the Small Employer Platinum Award, an applicant must satisfy only TWO of the

following five criteria (Items 21-25). Only fill out TWO of the items.

Item 21 – To satisfy this criterion, the employer's organization/resource group must:

Human Resources Veterans' Initiative means an initiative through which an employer provides support

for hiring, training, and retention of veteran employees.

This definition does not require that this support be provided by employees of the applicant. An

applicant can satisfy this criterion by contracting out or partnering with a third-party that provides this

support so long as the support provided otherwise meets this definition. For example, an employer may

work with an American Job Center that is part of the nationwide workforce development system, as

defined in section 3(67) of the Workforce Innovation and Opportunity Act, in satisfying this criterion.

Item 24 – 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;

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VETS1011-SP

• 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 2019 (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 25 – 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 26 – Explanation contained on form.

SECTION D: LABOR LAW VIOLATIONS

Item 27 – 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

ward:

1. Uniform

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;

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.

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VETS1011-SP

(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 E: ATTESTATION INFORMATION

Items 28-33 – 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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VETS1011-SP

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