Form 26-6681 Application for Fee or Roster Personnel Designation

OMB Control No. 2900-0113
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX

APPLICATION FOR FEE OR ROSTER
PERSONNEL DESIGNATION

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code
of Federal Regulations 1.576 for routine uses (for example: Authorized for release of information to Congress when requested for statistical purposes) as identified in the VA system of records,
(17VA26), Loan Guaranty Fee Personnel and Program Participant Records-VA, published in the Federal Register. Your obligation to respond is mandatory. Giving us your SSN account
information is mandatory. Applicants are required to provide their SSN under Chapter 37, Title 38 U.S.C. VA will not deny an individual benefits for refusing to provide his or her SSN unless
the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-0113, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 30 minutes per
respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance
Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0113 in any correspondence. Do not send your completed VA Form 26-6681 to this email address.

PENALTY: Failure to provide any of the requested information could affect the decision to approve your application since this decision will be
made only on the basis of available information we currently have on record. This may result in a delay in the processing of your application.

INSTRUCTIONS: Completed VA application may be uploaded and submitted to the ServiceNow Portal or contact VA at 1-877-827-3702 between 8:00 AM and
6:00 PM Eastern Standard time.
ETHNICITY AND RACE: Please provide both ethnicity and race. For race, you may check more than one designation.

DESIGNATION BEING APPLIED FOR:

REAL ESTATE APPRAISER

1. NAME OF APPLICANT (First, middle, last)
4. SEX (Voluntary information)

A. ETHNICITY

MALE
FEMALE

COMPLIANCE INSPECTOR

2. DATE OF BIRTH (MM/DD/YYYY)

3. SOCIAL SECURITY NUMBER

5. ETHNICITY AND RACE (Voluntary information)
B. RACE

HISPANIC OR LATINO

AMERICAN INDIAN OR ALASKAN NATIVE

NOT HISPANIC OR LATINO

ASIAN
BLACK OR AFRICAN AMERICAN

6. RESIDENCE ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

NATIVE HAWAIIAN OR OTHER
PACIFIC ISLANDER
WHITE

7. TELEPHONE NUMBER (Include Area Code)
8. E-MAIL ADDRESS
10. BUSINESS TELEPHONE NUMBER (Include Area Code)

9. BUSINESS ADDRESS (Address where Field Reviews are to be sent)

11. E-MAIL ADDRESS
12. PRESENT OCCUPATION

ITEM
A
B

EDUCATION
HIGH SCHOOL
COLLEGE

13. NAME AND ADDRESS OF PRESENT EMPLOYER

14. EDUCATION INFORMATION
DEGREE(S) AWARDED (If applicable)
NUMBER OF YEARS

15. ADVANCED EDUCATION OR TRAINING, VOCATIONAL, BUSINESS, OR SPECIAL COURSES (Enter course and school name and location)

17. CERTIFICATION/LICENSE INFORMATION
(Attach copy(ies) of applicable certification/license(s))

16. PROFESSIONAL ORGANIZATIONS OF WHICH YOU
ARE A MEMBER

A. KIND

18A. HAVE YOU BEEN PREVIOUSLY APPROVED BY
VA FOR A FEE POSITION?
YES
VA FORM
XXX XXXX

NO

B. CERTIFICATION/LICENSE
C. STATE
NUMBER
WHERE ISSUED

18B. OFFICE NAME AND ADDRESS

(If "Yes," complete Items 18B
and 18C)

26-6681

18C. DATES OF FEE ACTIVITY
FOR VA (MM/DD/YYYY)
FROM

SUPERSEDES VA FORM 26-6681, AUG 2021,
WHICH WILL NOT BE USED.

D. EXP. DATE
(MM/DD/YYYY)

TO
Page 1

19. GEOGRAPHIC AREA(S) OF PRACTICE (List your appraisal/inspection area(s), by State and County)

20. STATE PRINCIPAL ASSIGNMENTS DURING AT LEAST THE PAST 5 YEARS (Attach additional sheet as necessary)

A. PERIOD DATES (MM/DD/YYYY)
FROM

TO

B. NUMBER OF
ASSIGNMENTS

C. NAMES OF CLIENTS OR ORGANIZATIONS

21. EMPLOYMENT HISTORY DURING THE PAST 10 YEARS (Attach additional sheet as necessary)

A. DATES (MM/DD/YYYY)
FROM

TO

B. OCCUPATION

C. NAME OF EMPLOYER

D. ADDRESS

22. REFERENCES - LIST AND SUBMIT AT LEAST 2 LETTERS ATTESTING TO YOUR QUALIFICATIONS

(Two references must be from Fee Appraisers)

A. REFERENCES

23. NUMBER OF ASSIGNMENTS YOU WILL
ACCEPT PER WEEK

B. OCCUPATION

24. MAXIMUM NUMBER OF ASSIGNMENTS YOU
WILL ACCEPT AT ONE TIME

C. ADDRESS

25. E-MAIL ADDRESS

I, the undersigned, understand and agree that:
(a) VA may obtain a copy of my credit report.
(b) The approval of this application does not constitute my appointment as an agent or employee of the Department of Veterans Affairs.
(c) In performing fee work my status is that of an independent contractor.
(d) My sole interest in all transactions shall be to perform fee assignments as required by VA standards and criteria.

CERTIFICATION
I HEREBY CERTIFY THAT to the best of my knowledge all the information stated herein, as well as any information provided in the
accompaniment herewith, is true, accurate, and complete.
26. APPLICANT'S SIGNATURE (DO NOT PRINT) (Must be legible)

27. DATE SIGNED (MM/DD/YYYY)

REVIEWING OFFICIAL (Complete the following items)

THIS APPLICATION HAS BEEN REVIEWED AND I HEREBY RECOMMEND:
DESIGNATION

DISAPPROVAL

SIGNATURE OF REVIEWING OFFICER

VA FORM 26-6681, XXX XXXX

THIS APPLICANT IS BEING RECOMMENDED IN THE
APPRAISAL AREA(S) OF THE COUNTY(IES) OR STATE
LISTED BELOW:

DATE OF ACTION (MM/DD/YYYY)

Page 2