This form contains 46 fields organized into 15 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Applicant Information
Applicant Name Text
Provide your full name in the order of last name, first name, and middle name.
Max length: 75 characters
Home address (Street Number, City, State and ZIP Code) Text
Enter your complete home address on one line, including street number and name, apartment or unit (if any), city, state and ZIP code.
Eligibility Criteria
Veteran Currently Working – Yes ComboBox
Check this box if the veteran is currently working.
Veteran Currently Working – No ComboBox
Check this box if the veteran is not currently working.
Veteran employed by Federal civil service or D.C. Government – Yes ComboBox
Check this box if the veteran has been employed, or is now employed, by the Federal civil service or D.C. Government.
Veteran employed by Federal civil service or D.C. Government – No ComboBox
Check this box if the veteran has not been employed, nor is now employed, by the Federal civil service or D.C. Government.
Employment Dates
Employment Start Date Date
Enter the date on which the veteran’s employment with the Federal civil service or D.C. Government began. Fill only if the 'Has the veteran been employed, or is he/she now employed, by the Federal civil service or D.C. Government?' is 'Yes'.
Employment End Date Date
Enter the date on which the veteran’s employment with the Federal civil service or D.C. Government ended. Fill only if the 'Has the veteran been employed, or is he/she now employed, by the Federal civil service or D.C. Government?' is 'Yes'.
Family Member Preference
Option 9 – Mother of Disabled/Deceased Veteran CheckBox
Check this box if you are claiming 10-point veteran preference as the mother of a veteran who has a permanent and totally disabling service-connected disability or who is deceased, provided you are or were married to the veteran’s father and meet the specified marital and disability conditions.
Form Actions
Press Button to Print Form Button
Press this button to print the completed form.
Save Form Button
Press this button to save the completed form.
Press Button to Clear Form Button
Press this button to clear all fields in the form.
General
Street Address Text
Max length: 60 characters
City, State and ZIP Code Text
Max length: 60 characters
General Responses
7a. Currently Married to Veteran – Yes CheckBox
Check this box if you are currently married to the veteran.
7a. Currently Married to Veteran – No CheckBox
Check this box if you are not currently married to the veteran.
Military Service Details
Veteran Military Occupation at Separation Text
Provide the veteran’s military occupation or job title held at the time of separation from active duty service.
Max length: 40 characters
Spouse Preference Claims
7. Veterans' preference for a living veteran’s spouse based on service-connected disability CheckBox
Check this box if you are claiming a 10-point veterans’ preference as the spouse of a living veteran who, because of a service-connected disability, has been unable to qualify for a Federal Government job or any other position.
Veteran Employment Information
Veteran’s Present Occupation Text
Enter the veteran’s current job title or occupation. Fill only if the 'Is the veteran currently working?' is 'Yes'.
Max length: 80 characters
3. Enter What was the veteran's occupation, if any, before military service Text
Enter the occupation the veteran held, if any, before their military service.
Max length: 100 characters
Title and Grade of Position Text
Enter the title and grade of the position the veteran most recently held or currently holds in the Federal civil service or D.C. Government. Fill only if the 'Has the veteran been employed, or is he/she now employed, by the Federal civil service or D.C. Government?' is 'Yes'.
Max length: 50 characters
Agency Name and Address Text
Provide the name and full mailing address of the Federal or D.C. Government agency that employed the veteran. Fill only if the 'Has the veteran been employed, or is he/she now employed, by the Federal civil service or D.C. Government?' is 'Yes'.
Max length: 105 characters
Veteran Information
Veteran's Name Text
Provide the veteran’s last, first, and middle names exactly as they appear on official service records.
Max length: 75 characters
Veteran Preference Claims
Option 5 – Veterans' preference based on non-compensable service-connected disability, Purple Heart award, or DVA disability pension CheckBox
Check this box if you are claiming veterans’ preference under Option 5 based on a non-compensable service-connected disability, an award of the Purple Heart, or receipt of a disability pension administered by the Department of Veterans Affairs (DVA).
Option 6 – Veterans' preference based on a compensable service-connected disability of 10% or more CheckBox
Check this box if you are claiming veterans’ preference based on a compensable service-connected disability of 10% or more as determined by the Department of Veterans Affairs or disability retirement from a Military Service Department.
Veteran Preference Eligibility
Option 8a: Married at Time of Veteran’s Death – Yes CheckBox
Check this box if you were married to the veteran at the time of death.
Option 8a: Married at Time of Veteran’s Death – No CheckBox
Check this box if you were not married to the veteran at the time of death.
8b. Ever remarried - Yes CheckBox
Check this box if you have ever remarried. Fill only if the '8a. Were you married to the veteran at the time of death?' is Yes.
8b. Ever remarried - No CheckBox
Check this box if you have never remarried. Fill only if the '8a. Were you married to the veteran at the time of death?' is Yes.
Option 9a - Mother Currently Married – Yes CheckBox
Check this box if you are currently married.
Option 9a - Mother Currently Married – No CheckBox
Check this box if you are not currently married.
Option 9b – Are you separated? Yes CheckBox
Check this box if you are separated from the veteran’s father.
Option 9b – Are you separated? No CheckBox
Check this box if you are not separated from the veteran’s father.
Option 9c: Is your husband totally and permanently disabled? Yes CheckBox
Check this box if your husband is totally and permanently disabled. Fill only if the 'Are you separated?' is 'No'.
Option 9c: Is your husband totally and permanently disabled? No CheckBox
Check this box if your husband is not totally and permanently disabled. Fill only if the 'Are you separated?' is 'No'.
Option 9d - Veteran died on active duty (Yes) CheckBox
Check this box if the veteran died on active duty.
Option 9d - Veteran died on active duty (No) CheckBox
Check this box if the veteran did not die on active duty.
Resigned or Disqualified Due to Disability – Yes ComboBox
Check this box if the veteran has resigned from, been disqualified for, or separated from a position in the Federal civil service or D.C. Government because of a service-connected disability.
Resigned or Disqualified Due to Disability – No ComboBox
Check this box if the veteran has not resigned from, been disqualified for, or separated from a position in the Federal civil service or D.C. Government because of a service-connected disability.
Veteran receiving a civil service retirement pension – Yes ComboBox
Check this box if the veteran is receiving a civil service retirement pension.
Veteran receiving a civil service retirement pension – No ComboBox
Check this box if the veteran is not receiving a civil service retirement pension.
Veteran Service Details
Branch of Service Text
Enter the branch of military service in which the veteran served during this service period.
Max length: 35 characters
Date Entered Active Duty Date
Enter the date on which the veteran entered active duty for this service period.
Date Separated or Released from Active Duty Date
Enter the date on which the veteran separated or was released from active duty for this service period, if applicable.
Civil Service Annuity (CSA) Number Text
Enter the veteran’s Civil Service annuity (CSA) or Federal employee retirement annuity number. Fill only if the 'Is the veteran receiving a civil service retirement pension?' is 'Yes'.
Max length: 15 characters
Widow/Widower Preference Claims
8. Veterans' preference for a veteran's widow or widower CheckBox
Check this box if you are the veteran’s widow or widower claiming 10-point preference under Option 8.