Fill - Free fillable HIRE Vets Medallion Program Demonstration Paper Application 2018 PDF form

HIRE Vets Medallion Program Demonstration

Paper Application Forms

Calendar Year 2018

In Calendar Year (CY) 2018, VETS will engage in a limited demonstration of the HIRE Vets Medallion

Program voluntary recognition program, before initiation of the first HIRE Vets Medallion Award cycle.

The CY 2018 program demonstration will collect the same information as that approved for the HIRE

Vets Medallion Program Final Rule (OMB Control No. 1293-0015). The only differences between the

application forms for the HIRE Vets Medallion Program Final Rule and the CY 2018 HIRE Vets

Medallion Program Demonstration are that fields associated with application fee payment will not be used

(VETS will not collect application fees as part of the demonstration program), and statements on the

application forms referring to the “2019 HIRE Vets Application” will instead read “2018 HIRE Vets

Application.” In addition, the CY 2018 HIRE Vets Medallion Program Demonstration will limit the

number of applicants. VETS intends to inform applicants up front that a fee is not required for the CY

2018 HIRE Vets Medallion Program Demonstration.

PAGE 1

Item 10 Employer Size: Did you have 50 or less employees as of December 31 of the year prior to the year

in which you are submitting the application? Example, if applying for the 2019 award, you must have had 50

or less employees on December 31, 2018. 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. "Empl

oyees" does not include temporary

workers. For additional information about the definition of employee, temporary worker, and veteran please

see the instructions. Yes:

VETS-1011SG

OMB No. 1293-0015

Form expires

HIRE Vets Medallion Award Application

Small Employer - Gold Award

Item 11 Medallion Level: Confirm you are applying for the Gold level. Yes:

SECTION A: EMPLOYER INFORMATION

Item 8 Employer Zip Code or Postal Code

Enter the zip code or postal code.

Item 7 Employer State or Province

Enter the state or province.

Item 6 Employer City or Town

Enter the city or town.

Item 9 Country

Enter country name.

Please do not abbreviate the country name

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.

Please note that this form includes accompanying instructions for the Small Employer Gold 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 Gold Award at the end of this document prior to completing and submitting the application.

Item 5 Employer Street Address

Enter the official address (number, street, room or

suite number, of the employer's principal office or

place of business) for the employer listed in Item 1.

Item 14 The The veteran hiring percentage in 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 75% for the applicant

to qualify for the Small Employer Gold Award.

SECTION B:

VETERAN EMPLOYEE CRITERIA

PAGE 2

VETS-1011SG

OMB No. 1293-0015

Item 13 Enter the total number of employees (including veterans) hired in the preceding CY.

Item 12 Enter the number of veterans hired in the preceding calendar year (CY).

Example, if applying for the 2019 award, enter the number of veterans hired during the 2018 CY.

Item 16 Enter the number of veterans hired in the CY preceding the preceding CY who

remained with the employer for at least 12 months.

Example, if applying for the 2019 award, enter the number of veteran employees hired in 2017

who were retained for at least 12 months from the date of hire.

RETENTION: 75% Requirement

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

Example, if applying for the 2019 award, enter the number of veterans hired during the 2017 CY.

HIRING: 7% Requirement

HIRE Vets Medallion Award Application

Small Employer - Gold Award

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

Item 18 divided by Item 19. Item 20 must be not less than 7% for the applicant to qualify

for the Small Employer Gold Award.

VETERAN EMPLOYEE PERCENTAGE: 7% Requirement

Item 18 Enter the total number of veterans employed on December 31st of the preceding

CY. Example, if applying for the 2019 award, enter the number of veteran employees as of December

31, 2018.

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

December 31st of the preceding CY.

Example, if applying for the 2019 award, enter the total number of employees as of December 31,

2018.

AND

Item 12 divided by Item 13. Item 14 must be not less than 7% for the applicant to qualify

for the Small Employer Gold 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 gold award, the employer must fill out and satisfy either the hiring

requirement or the retention and veteran employee percentage requirements.

0.0%

PAGE 3

HIRE Vets Medallion Award Application

Small Employer - Gold Award

Item 21 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 receives an award.

(1,000 character limit)

VETS-

1011SG

OMB No. 1293-0015

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 5.25 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.

Item 27 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.

Clicking on the "I Agree" button below, constitutes your making the above attestation under penalty of perjury.

I Agree

SECTION D: ATTESTATION INFORMATION For Items 23-24,

provide information for the person attesting to Item 27.

Item 23 Name:

Item 24 Title:

Item 25 Contact email address:

Item 26 Contact phone number:

PAGE 4

I Agree

SECTION C: LABOR LAW VIOLATIONS

Item 22:

As further explained in Item 22 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.

HIRE Vets Medallion Award Application

Small Employer

- Gold Awar

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.

VETS-1011SG

OMB No.

1293-0015

Page | 5 VETS1011- S G

The following instructions are designed to assist in properly applying for the HIRE Vets Medallion Award.

Before an application is submitted, please ensure that:

- The employer did not receive an award in the previous calendar year. Employers who received an

award in the previous calendar year are not eligible for an award.

- All information is 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 Award 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 Award Program.

Please use these definitions when filling out the application for the Small Employer Gold 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.

Vet

eran 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

Instructions

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 VETS1011- S G

SECTION B: VETERAN EMPLOYEE CRITERIA

Items 12-21 – Explanation contained on form

SECTION C: LABOR LAW VIOLATIONS

Item 22 – 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:

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:

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.

(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 co

ntract debarment means any order or voluntary

agreement, pursuant to the laws listed in paragraph (a) of this section, which 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, which 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.

Items 3-11 – Explanation contained on form

Page | 7 VETS1011- S G

To receive a HIRE Vets Medallion Award, the employer must not have any violations identified in the

above regul

atory 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 D: ATTESTATION INFORMATION

Items 23-28 – 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 regulations at 20 CFR part 1011 and the HIRE Vets Act. To

the extent that anything in these instructions contradict the regulations or Act, the regulations and Act

govern.

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