VETS-1011SG HIRE Vets Application Small Employer Gold (Paper)

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HIRE Vets Medallion Award Application
Small Employer - Gold Award

VETS-1011SG
OMB No. 1293-0015
Form expires 1/31/21

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.
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 2018 (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.
Yes:
Item 11 Medallion Level: Are you applying for the gold level?

Yes:

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HIRE Vets Medallion Award Application
Small Employer - Gold Award

VETS-1011SG
OMB No. 1293-0015

SECTION B: VETERAN EMPLOYEE CRITERIA
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.
HIRING: 7% Requirement
Item 12 Enter the number of veterans hired in 2018 (the preceding calendar year (CY)).
Item 13 Enter the total number of employees (including veterans) hired in 2018 (the preceding CY).
Item 14 The veteran hiring percentage in 2018 (the preceding CY) was..............................................
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.

0.0%

OR
RETENTION: 75% Requirement
Item 15 Enter the number of veterans hired in 2017 (the CY preceding the preceding CY).
Item 16 Enter the number of veterans hired in 2017 (the CY preceding the preceding CY) who
remained with the employer for at least 12 months.
Item 17 The percentage of veterans retained for 12 months was........................................................

0.0%

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.

AND
VETERAN EMPLOYEE PERCENTAGE: 7% Requirement
Item 18 Enter the total number of veterans employed on December 31 of 2018 (the preceding CY).
Item 19 Enter the total number of employees (including veterans) with the company on December
31 of 2018 (the preceding CY).
Item 20 The proportion of veteran employees is.................................................................................
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.

0.0%

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HIRE Vets Medallion Award Application
Small Employer - Gold Award

VETS-1011SG
OMB No. 1293-0015

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)

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HIRE Vets Medallion Award Application
Small Employer - Gold Award

VETS-1011SG
OMB No. 1293-0015

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.
I agree
SECTION D: ATTESTATION INFORMATION For Items 23-24, provide information for the person attesting to Item 27.
Item 23 First and Last Name:
Item 24 Title:
Item 25 Contact Email Address:
Item 26 Contact Phone Number:
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.
Entering your name in Item 23 above and then clicking on the "I agree" button below constitutes your signing the
above attestation under penalty of perjury.
I agree
Item 28 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.

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Instructions

VETS1011-SG

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 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.
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.

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VETS1011-SG

Items 3-11 – Explanation contained on form.
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:
1.
2.

Uniformed Services Employment and Reemployment Rights Act (USERRA);
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.
(c)
For purposes of this application, a stipulated agreement means any agreement
(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.

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VETS1011-SG

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 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.