VA21a, APPLICATION FOR ACCREDITATION AS A CLAIMS AGENT OR ATTORNEY

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1 Form Approved, OMB No. 2900-0605 Respondent Burden: 45 minutes APPLICATION FOR ACCREDITATION AS A CLAIMS AGENT OR ATTORNEY Please provide the applicable personal and employment data, then read each question and provide complete answers to all questions that apply to INSTRUCTIONS: you. If additional space is needed, please attach a supplementary page(s). After providing all of the requested information, sign and date your application. Unsigned or incomplete applications will not be processed. Send completed applications to: Department of Veterans Affairs, Office of the General Counsel (022D), 810 Vermont Avenue, NW, Washington, D.C. 20420. After an affirmative determination of character and fitness for practice before the VA, claims agent applicants must achieve a score of 75 percent or more on a written examination administered VA as a prerequisite to acreditation. Claims agent applicants will be given written instructions for arranging to take the examination if initial eligibility is established. Attorney applicants must be in good standing with a State bar and are not required to take an examination administered by VA as a prerequisite to accreditation. Denials of initial eligibility for accreditation as a claims agent or attorney are final and are not subject to appeal, but applicants may reapply. (street, city, state, ZIP Code) 2B. PHONE NUMBER (Including area code) 2A. HOME ADDRESS 1. LAST NAME - FIRST NAME - MIDDLE NAME (If available) 2C. E-MAIL ADDRESS 3A. EMPLOYMENT STATUS 3B. WORK ADDRESS (City, State, Country) 5. PLACE OF BIRTH (street, city, state, ZIP Code) EMPLOYED (Complete Item 3B) 6. BRANCH OF SERVICE 7. CHARACTER OF DISCHARGE (Skip Item 3B) UNEMPLOYED (Skip Item 3B) SELF-EMPLOYED (Skip Item 3B) STUDENT 4. DATE OF BIRTH (Month, day, year) 8. LIST DATES OF ALL ACTIVE MILITARY SERVICE 9. EMPLOYMENT (Provide information for past five years - use additional sheets if necessary) D. EMPLOYMENT A. EMPLOYER NAME AND ADDRESS B. EMPLOYER PHONE NO. E. NAME OF SUPERVISOR C. POSITION TITLE DATES (street, city, state, ZIP Code) (Include area code) (Month/Day/Year) EXTENSION: EXTENSION: EXTENSION: (Provide information for high school graduation and list all colleges or universities attended and degrees received) 10. EDUCATION A. NAME AND ADDRESS OF INSTITUTION B. DATES ATTENDED C. DEGREE RECEIVED/MAJOR (street, city, state, ZIP Code) (Month/Year) VA FORM MAY 2007 21a

2 11A. ARE YOU CURRENTLY A MEMBER IN GOOD 11B. IF "YES," LIST EACH JURISDICTION IN WHICH ADMITTED, THE DATE OF ADMISSION, AND STANDING OF THE BAR OF THE HIGHEST COURT MEMBERSHIP OR REGISTRATION NUMBER. OF A STATE OR TERRITORY OF THE UNITED STATES? DATE OF ADMISSION MEMBERSHIP OR REGISTRATION NO. JURISDICTION IN WHICH ADMITTED NO YES 12A. ARE YOU CURRENTLY ADMITTED TO PRACTICE 12B. IF "YES," LIST EACH AGENCY OR FEDERAL COURT TO WHICH ADMITTED, THE DATE OF BEFORE ANY STATE OR FEDERAL AGENCY OR ANY ADMISSION, AND MEMBERSHIP OR REGISTRATION NUMBER. FEDERAL COURT? AGENCY IN WHICH ADMITTED DATE OF ADMISSION MEMBERSHIP OR REGISTRATION NO. NO YES Truthfulness and candor are essential elements of good moral character and reputation relevant to practice before the Department BACKGROUND INFORMATION: of Veterans Affairs. It is in your best interest; therefore, to provide the Office of the General Counsel with all available information in responding to the questions asked below. For each question answered "YES," provide a detailed statement setting forth all relevant facts and dates along with copies of relevant documents. Your responses must be updated as necessary prior to your accreditation. Failure to disclose the requested information may result in denial of accreditation under 38 C.F. R. § 14.629 or in disciplinary proceedings under 38 C.F.R. § 14.633 if you are already accredited. (no contest) , but omit (1) traffic fines of $300 or less, For questions 13 through 15 your answers should include convictions resulting from a plea of nolo contendere (2) any violation of law committed before your 16th birthday, and (3) any conviction for which the record was expunged under Federal or state law. 13B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURRENCE, AND THE NAME 13A. HAVE YOU EVER BEEN CONVICTED, AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED. IMPRISONED, SENTENCED TO PROBATION OR PAROLE? (Include felonies, firearms or explosives violations, misdemeanors, and all other offenses.) YES NO 14A. HAVE YOU EVER BEEN CONVICTED, 14B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURRENCE, AND THE NAME (If no BY A MILITARY COURT-MARTIAL? AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED. military service, answer "NO,") NO YES 15B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURENCE, AND THE NAME 15A. ARE YOU NOW UNDER CHARGES FOR ANY VIOLATION OF LAW? AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED. YES NO 16. HAVE YOU EVER BEEN SUSPENDED, EXPELLED OR ASKED TO RESIGN OR WITHDRAW FROM ANY EDUCATIONAL INSTITUTION, OR HAVE YOU RESIGNED OR WITHDRAWN FROM ANY SUCH INSTITUTION IN TIME TO AVOID DISCIPLINE, SUSPENSION, OR EXPULSION FOR CONDUCT INVOLVING DISHONESTY, FRAUD, MISREPRESENTATION, OR DECEIT? YES NO 17. HAVE YOU EVER BEEN DISCIPLINED, REPRIMANDED, SUSPENDED OR TERMINATED IN ANY JOB FOR CONDUCT INVOLVING DISHONESTY, FRAUD, MISREPRESENTATION, DECEIT, OR ANY VIOLATION OF FEDERAL OR STATE LAWS OR REGULATIONS? YES NO 18. HAVE YOU EVER RESIGNED, RETIRED FROM, OR QUIT A JOB WHEN YOU WERE UNDER INVESTIGATION OR INQUIRY FOR CONDUCT WHICH COULD HAVE BEEN CONSIDERED AS INVOLVING DISHONESTY, FRAUD, MISREPRESENTATION, DECEIT, OR VIOLATION OF FEDERAL OR STATE LAWS OR REGULATIONS, OR AFTER RECEIVING NOTICE OR BEING ADVISED OF POSSIBLE INVESTIGATION, INQUIRY, OR DISCIPLINARY ACTION FOR SUCH CONDUCT? YES NO 19. HAVE YOU EVER FUNCTIONED AS A REPRESENTATIVE, AGENT, OR ATTORNEY BEFORE A STATE OR FEDERAL DEPARTMENT OR AGENCY? YES NO VA FORM 21a, MAY 2007, PAGE 2

3 20. HAVE YOU EVER BEEN REPRIMANDED, SUSPENDED, OR BARRED FROM PRACTICE BEFORE ANY COURT, BAR, OR FEDERAL OR STATE AGENCY, OR HAVE YOU RESIGNED MEMBERSHIP IN THE BAR OF ANY COURT, OR FEDERAL OR STATE AGENCY TO AVOID REPRIMAND, SUSPENSION, OR DISBARMENT FOR CONDUCT INVOLVING DISHONESTY, FRAUD, MISREPRESENTATION, OR DECEIT? YES NO 21. HAVE YOU EVER APPLIED FOR ACCREDITATION BY THE DEPARTMENT OF VETERANS AFFAIRS AS A REPRESENTATIVE OF A VETERANS SERVICE ORGANIZATION, AGENT, OR ATTORNEY? YES NO 22. IF YOU WERE PREVIOUSLY ACCREDITED AS A REPRESENTATIVE OF A VETERANS SERVICE ORGANIZATION, WAS THAT ACCREDITATION TERMINATED OR SUSPENDED AT THE REQUEST OF THE ORGANIZATION? NO YES 23A. DO YOU HAVE ANY CONDITION OR IMPAIRMENT (SUCH AS SUBSTANCE ABUSE, ALCOHOL ABUSE, OR A MENTAL, EMOTIONAL, NERVOUS, OR BEHAVIORAL DISORDER OR CONDITION) THAT IN ANY WAY CURRENTLY AFFECTS, OR, IF UNTREATED OR NOT OTHERWISE ACTIVELY MANAGED, COULD AFFECT YOUR ABILITY TO REPRESENT CLAIMANTS IN A COMPETENT AND PROFESSIONAL MANNER? YES NO 23B. IF YOU ANSWERED "YES," TO ITEM 23A, PLEASE DESCRIBE THE CONDITION OR IMPAIRMENT, AND ANY TREATMENT YOU RECEIVED IN THE PAST YEAR OR RECEIVE NOW. IF YOU HAVE BEEN UNDER THE CARE OR SUPERVISION OF A HEALTH-CARE PROFESSIONAL, SUBMIT A STATEMENT BY THE HEALTH-CARE PROFESSIONAL SPECIFYING YOUR CURRENT DIAGNOSIS, TREATMENT REGIMEN, AND PROGNOSIS, AND ITS BEARING ON YOUR FITNESS TO REPRESENT CLAIMANTS BEFORE THE DEPARTMENT OF VETERANS AFFAIRS. 24A. DO YOU HAVE ANY PHYSICAL LIMITATIONS WHICH WOULD INTERFERE WITH YOUR COMPLETION OF A WRITTEN EXAMINATION ADMINISTERED UNDER THE SUPERVISION OF A VA REGIONAL COUNSEL (Claims agent applicants only) ? YES NO 24B. IF "YES," PLEASE STATE THE NATURE OF SUCH LIMITATIONS AND PROVIDE DETAILS OF ANY SPECIAL ACCOMMODATIONS DEEMED NECESSARY. 25. CHARACTER REFERENCES (Please provide the full names, addresses, and current phone numbers of three individuals who are not immediate family members and who have personal knowledge of your character and qualifications to serve as a claims agent or attorney.) PHONE NUMBER RELATIONSHIP TO ADDRESS NAME (Include area code) APPLICANT EXTENSION: EXTENSION: EXTENSION: CERTIFICATION: I CERTIFY THAT the statements and entries on this form are true and correct. (A willfully false statement or certification is a criminal offense and is punishable by law [18 U.S.C. 1001]). SIGNATURE OF APPLICANT (Ink Signature) DATE SIGNED VA FORM 21a, MAY 2007, PAGE 3

4 PRIVACY ACT The information requested on this form is solicited under Section 5904, Title 38, United States Code and Section INFORMATION: initial of Code of Federal Regulations. It will enable VA to determine 38, eligibility for accreditation as a claims agent or attorney to 14.629(b) Title claimants before VA. Any information on this form may represent disclosed outside VA only if authorized under the Privacy Act, including the be routine identified in the VA system of records, 01VA022, uses and Former Accredited Representative, Claims Agent, Attorney, and Current Representative, Claims Agent, and Attorney Applicant and Rejected Applicant Records--VA, published in the Federal Register. Routine disclosures may be for the following purposes: civil or criminal law enforcement or investigation; congressional communications; communications relevant made litigation the of VA benefits; verification of identity and status; to conducted by the Department of Justice; and communication with delivery employing entities and governmental licensing organizations concerning information relevant to employment or licensing of a prospective, present, or furnish former claims agent or attorney. Providing the requested information is voluntary; however, failure to representative, information may delay or prevent action on the application. RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB Control Number. Public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have comments regarding this burden estimate or any other aspect of this collection of information send your comments to VA Clearance Officer (005R1B), 810 Vermont Avenue, NW, Washington, D.C. 20420. Please do not send applications for accreditation to this address. VA FORM 21a, MAY 2007, PAGE 4

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