Va Form 21A – Fill Out and Use

Form Approved, OMB No. 2900-0605

Expiration Date: Mar. 31, 2022

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.

9.EMPLOYMENT (Provide information for past five years - use additional sheets if necessary)

A. EMPLOYER NAME AND ADDRESS	B. EMPLOYER PHONE NO.	C. POSITION TITLE	D. EMPLOYMENT	E. NAME OF SUPERVISOR
(street, city, state, ZIP Code)	(Include area code)		DATES
			(Month/Day/Year)
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10.EDUCATION (Provide information for high school graduation and list all colleges or universities attended and degrees received)

VA FORM	21a	PREVIOUS VERSIONS OF THIS FORM WILL NOT BE USED.
APR 2020

11A. ARE YOU CURRENTLY A MEMBER IN GOOD		11B. IF "YES," LIST EACH JURISDICTION IN WHICH ADMITTED, THE DATE OF ADMISSION, AND
STANDING OF THE BAR OF THE HIGHEST COURT		MEMBERSHIP OR REGISTRATION NUMBER.
OF A STATE OR TERRITORY OF THE UNITED STATES?
		JURISDICTION IN WHICH ADMITTED	DATE OF ADMISSION	MEMBERSHIP OR REGISTRATION NO.
YES	NO
12A. ARE YOU CURRENTLY ADMITTED TO PRACTICE		12B. IF "YES," LIST EACH AGENCY OR FEDERAL COURT TO WHICH ADMITTED, THE DATE OF
BEFORE ANY STATE OR FEDERAL AGENCY OR ANY		ADMISSION, AND MEMBERSHIP OR REGISTRATION NUMBER.
FEDERAL COURT?
		AGENCY IN WHICH ADMITTED	DATE OF ADMISSION	MEMBERSHIP OR REGISTRATION NO.
YES	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,		13B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURRENCE, AND THE NAME
IMPRISONED, SENTENCED TO		AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED.
PROBATION OR PAROLE?	(Include felonies,
firearms or explosives violations, misdemeanors,
and all other offenses.)
YES	NO
14A. HAVE YOU EVER BEEN CONVICTED,		14B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURRENCE, AND THE NAME
BY A MILITARY COURT-MARTIAL? (If no		AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED.
military service, answer "NO,")
YES	NO
15A. ARE YOU NOW UNDER CHARGES		15B. IF "YES," PROVIDE THE DATE, EXPLANATION OF THE VIOLATION, PLACE OF OCCURRENCE, AND THE NAME
FOR ANY VIOLATION OF LAW?		AND ADDRESS OF THE MILITARY AUTHORITY OR COURT INVOLVED.
YES	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?

YESNO

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?

YESNO

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

VA FORM 21a, APR 2020, PAGE 2

PREVIOUS VERSIONS OF THIS FORM WILL NOT BE USED.

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?

YESNO

21.HAVE YOU EVER APPLIED FOR ACCREDITATION BY THE DEPARTMENT OF VETERANS AFFAIRS AS A REPRESENTATIVE OF A VETERANS SERVICE ORGANIZATION, AGENT, OR ATTORNEY?

YESNO

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?

YESNO

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?

YESNO

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 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 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.)

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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]).

VA FORM 21a, APR 2020, PAGE 3

PREVIOUS VERSIONS OF THIS FORM WILL NOT BE USED.