Form VA21a Application for Accreditation as a Claims Agent or Attor

Form Approved, OMB No. 2900-0605
Expiration Date: Xxx, 20XX
Respondent Burden: 45 minutes

APPLICATION FOR ACCREDITATION AS A CLAIMS AGENT OR ATTORNEY
INSTRUCTIONS: Please provide the applicable personal and employment data, then read each question and provide complete answers to all questions that apply to
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. Please type or print legibly.
1A. LAST NAME - FIRST NAME - MIDDLE NAME

2A. HOME ADDRESS (street, city, state, ZIP Code)

2B. HOME PHONE NUMBER (Including area code)

2C. E-MAIL ADDRESS (If available)

1B. GENDER

MALE

3A. EMPLOYMENT STATUS

FEMALE
3B. WORK ADDRESS (Business name, street, city, state, ZIP Code) 3C. WORK PHONE NUMBER
(Including area code)

4. DATE OF BIRTH (Month, day, year)

EMPLOYED (Complete Item 3B)
EMPLOYED BY THE FEDERAL
GOVERNMENT (Complete Item 3B)

5. PLACE OF BIRTH (City, State, Country)

UNEMPLOYED (Skip Item 3B)

6. BRANCH OF SERVICE

SELF-EMPLOYED (Complete
Item 3B)

7. CHARACTER OF DISCHARGE

8. LIST DATES OF ALL ACTIVE MILITARY SERVICE

STUDENT (Skip Item 3B)

9. EMPLOYMENT (Provide information for past five years beginning with current employment. Use additional sheets if necessary)
A. EMPLOYER NAME AND ADDRESS
(street, city, state, ZIP Code)

B. EMPLOYER PHONE NO.
(Include area code)

C. POSITION TITLE

D. EMPLOYMENT
DATES
(Month/Day/Year)

E. NAME OF SUPERVISOR

EXTENSION:

EXTENSION:

EXTENSION:

10. EDUCATION (Provide information for high school graduation and list all colleges or universities attended and degrees received)
A. NAME AND ADDRESS OF INSTITUTION
(City and state)

VA FORM
APR 2014

21a

B. DATES ATTENDED
(Month/Year)

C. DEGREE RECEIVED/MAJOR

11A. ARE YOU CURRENTLY A MEMBER IN GOOD
STANDING OF THE BAR OF THE HIGHEST COURT
OF A STATE OR TERRITORY OF THE UNITED
STATES?

YES

NO

12A. ARE YOU CURRENTLY ADMITTED TO
PRACTICE BEFORE ANY STATE OR FEDERAL
AGENCY OR ANY FEDERAL COURT?

YES

11B. IF "YES," LIST EACH JURISDICTION IN WHICH ADMITTED, THE DATE OF ADMISSION, MEMBERSHIP
STATUS, AND MEMBERSHIP OR REGISTRATION NUMBER.
MEMBERSHIP OR
ACTIVE/INACTIVE
JURISDICTION IN WHICH ADMITTED
DATE OF ADMISSION
REGISTRATION NO.
OTHER

12B. IF "YES," LIST EACH AGENCY OR FEDERAL COURT TO WHICH ADMITTED, THE DATE OF
ADMISSION, AND MEMBERSHIP OR REGISTRATION NUMBER.
AGENCY/COURT IN WHICH ADMITTED

DATE OF ADMISSION

MEMBERSHIP OR REGISTRATION NO.

NO

BACKGROUND INFORMATION: Truthfulness and candor are essential elements of good moral character and reputation relevant to practice before the Department
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" in questions 13 through 24, provide a detailed statement setting forth all relevant facts and dates along with copies of
relevant documents. Please use additional pages, as necessary.
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.
For questions 13 through 15 your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less,
(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.
13A. HAVE YOU EVER BEEN CONVICTED,
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, BY A
MILITARY COURT-MARTIAL? (If no military service
answer "NO.")
YES

14B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURRENCE, AND THE
NAME AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED.

NO

15A. ARE YOU NOW UNDER CHARGES FOR ANY
VIOLATION OF LAW?

YES

13B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURRENCE, ANY
SENTENCE OR PENALTIES RECEIVED, AND THE NAME AND ADDRESS OF THE MILITARY AUTHORITY OR
COURT INVOLVED.

15B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURENCE, AND THE
NAME AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED.

NO

16A. 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

16B. IF "YES," PLEASE EXPLAIN AND PROVIDE RELEVANT DOCUMENTS.

17A. 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

17B. IF "YES," PLEASE EXPLAIN AND PROVIDE RELEVANT DOCUMENTS.

18A. 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

18B. IF "YES," PLEASE EXPLAIN AND PROVIDE RELEVANT DOCUMENTS.

VA FORM 21a, APR 2014, PAGE 2

19A. 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

19B. IF "YES," PLEASE EXPLAIN AND PROVIDE RELEVANT DOCUMENTS.

20A. HAVE YOU EVER FUNCTIONED AS A REPRESENTATIVE, AGENT, OR ATTORNEY BEFORE A STATE OR FEDERAL DEPARTMENT OR AGENCY?
YES

NO

20B. IF "YES," PLEASE EXPLAIN.

21A. 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

21B. IF "YES," PLEASE EXPLAIN.

22A. 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?
YES

NO

N/A

22B. IF "YES," PLEASE EXPLAIN AND PROVIDE RELEVANT DOCUMENTS.

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

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.)
NAME

ADDRESS

PHONE NUMBER
(Include area code)

RELATIONSHIP TO
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

VA FORM 21a, APR 2014, PAGE 3

DATE SIGNED

PRIVACY ACT INFORMATION: The information requested on this form is solicited under Section 5904, Title 38, United States Code and Section
14.629(b) of Title 38, Code of Federal Regulations. It will enable VA to determine initial eligibility for accreditation as a claims agent or attorney to
represent claimants before VA. Any information on this form may be disclosed outside VA only if authorized under the Privacy Act, including the
routine uses identified in the VA system of records, 01VA022, Accreditation Records--VA, published in the Federal Register. Routine disclosures
may be made for the following purposes: background checks, civil or criminal law enforcement or investigation; congressional communications;
communications relevant to the delivery of VA benefits; verification of identity and status; litigation conducted by the Department of Justice; and
communication with employing entities and governmental licensing organizations concerning information relevant to employment or licensing of a
prospective, present, or former representative, claims agent or attorney. Providing the requested information is voluntary; however, failure to furnish
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, APR 2014, PAGE 4