Fill - Free fillable HIRE Vets Medallion Program Demonstration Paper Application Forms (Department of Labor) 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

permanent full-time and permanent part-time employees. "Employees" does not include temporary workers.

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

instructions. yes:

VETS-1011SP

OMB No. 1293-0015

Form expires

HIRE Vets Medallion Award Application

Small Employer - Platinum Award

Item 11 Medallion Level: Are you applying for the Platinum 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, input it here.

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.

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 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 85% for the applicant to

qualify for the Small Employer Platinum Award.

SECTION B:

VETERAN EMPLOYEE CRITERIA

PAGE 2

VETS-1011SP

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.

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: 10% Requirement

RETENTION: 85% Requirement

HIRE Vets Medallion Award Application

Small Employer - Platinum Award

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.

VETERAN EMPLOYEE Percentage: 10% 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 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.

0.0%

PAGE 3

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)

SECTION C: INTEGRATION ASSISTANCE CRITERIA

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

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

(1,000 character

limit)

(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

requirements.

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

VETS-1011SP

OMB No. 1293-0015

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 receives 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)

PAGE 4

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

VETS-1011SP

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 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.

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

I Agree

SECTION E: ATTESTATION INFORMATION

For Items 28-29, provide information for the

person attesting to Item 32.

Item 28 Name:

Item 29 Title:

Item 30 Contact email address:

Item 31 Contact phone number:

PAGE 5

I Agree

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.

HIRE Vets Medallion Award Application

Small Employer

- Platinum 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-1011SP

OMB No. 1293-0015

Page | 6 VETS1011- S P

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 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 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 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.

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 | 7 VETS1011- S P

SECTION B: VETERAN EMPLOYEE C

RITERIA

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:

• 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 the year prior to the calendar year in which the

employer applies for the award. For example, if an employer applies for an award in 2020, the

organization or group must still be in existence on December 31, 2019.

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 the year prior to the calendar year in which the

employer applies for the award. For example, if an employer applies for an award in 2020, the

leadership program must still be in existence on December 31, 2019.

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 crit

erion, 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 the year prior to the calendar year in which the

employer applies for the award. For example, if an employer applies for an award in 2020, the

initi

ative must be in existence on December 31, 2019.

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.

Items 3-11 – Explanation contained on form

Page | 8 VETS1011- S P

Item 24 – To satisfy this criterion, employers must:

• pro

vide 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 the year prior to the

calendar year in which the employer applies for the award. For example, if an employer applies

for an award in 2020, the pay differential must still be in existence on December 31, 2019.

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 the year

prior to the calendar year in which the employer applies for the award. For example, if an

employer applies for an award in 2020, the tuition assistance program must still be in existence

on December 31, 2019.

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 award:

Page | 9 VETS1011- S P

Uniformed Services Employment and Reemployment Rights Act (USERRA);

2. Vietn

am 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 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 h

ave any violations identified in the

above re

gulatory 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

Page | 10 VETS1011- S P

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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