VA21a Application for Accreditation as a Claims Agent or Attor

Form Approved, OMB No. 2900-0605
Expiration Date: XXX. XX, 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 VA, claims agent applicants must achieve a score
of 75 percent or more on a written examination administered by VA as a prerequisite to accreditation. 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.
2A. HOME ADDRESS (street, city, state, ZIP Code)

1. LAST NAME - FIRST NAME - MIDDLE NAME

2B. PHONE NUMBER (Including area code)

2C. E-MAIL ADDRESS

3A. EMPLOYMENT STATUS

3B. WORK ADDRESS (street, city, state, ZIP Code)

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

EMPLOYED (Complete Item 3B)
6. BRANCH OF SERVICE

UNEMPLOYED (Skip Item 3B)

7. CHARACTER OF DISCHARGE

SELF-EMPLOYED (Skip Item 3B)
STUDENT (Skip Item 3B)

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

8. LIST DATES OF ALL ACTIVE MILITARY SERVICE

9. EMPLOYMENT (Provide information, including volunteer work and self-employment, for past five years - 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
(MM/DD/YYYY)

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

(street, city, state, ZIP Code)

VA FORM
XXX XXXX

21a

B. DATES ATTENDED

(Month/Year)

PREVIOUS VERSIONS OF THIS FORM WILL NOT BE USED.

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

11B. IF "YES," LIST EACH JURISDICTION IN WHICH ADMITTED, THE DATE OF ADMISSION, AND
MEMBERSHIP OR REGISTRATION NUMBER.
JURISDICTION IN WHICH ADMITTED

(MM/DD/YYYY)

MEMBERSHIP OR REGISTRATION NO.

NO

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

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

YES

DATE OF ADMISSION

DATE OF ADMISSION

(MM/DD/YYYY)

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," 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.
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

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

or explosives violations,
misdemeanors, and all other offenses.)
YES

NO

14A. HAVE YOU EVER BEEN
CONVICTED, BY A MILITARY COURTMARTIAL? (If no military service,

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.

answer "NO,")

YES

NO

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

YES

15B. 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

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

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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?
YES

NO

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 HEALTHCARE 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 DISTRICT 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 e-mail addresses 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

E-MAIL

RELATIONSHIP TO
APPLICANT

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)

VA FORM 21a, XXX XXXX, PAGE 3

DATE SIGNED (MM/DD/YYYY)

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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: 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: 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 2900-0605, and it expires XX/XX/20XX. Public
reporting burden for this collection of information is estimated to average 45 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. 2900-0605 in any correspondence. Do not
send your completed VA Form 21a to this email address.
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PREVIOUS VERSIONS OF THIS FORM WILL NOT BE USED.