VA Form 21 Accreditation

Section 1 of 14

Designee Name

Section I is completed by the designee (Type or print).

Last Name: *

First Name: *

Middle Name:

Section 2 of 14

Home Address (Item 2A)

Home Address: * Street, city, state, ZIP code.

Section 3 of 14

Business Address (Item 2B)

Business Address: Street, city, state, ZIP code.

Section 4 of 14

Branch of Service (Item 3)

Check all applicable boxes.

Section 5 of 14

Dates of All Active Service (Item 4)

List of Dates of All Active Service: Example: 06/2004 to 08/2010, 01/2012 to 05/2015

Section 6 of 14

Character of Discharge(s) (Item 5)

Character of Discharge(s): Example: Honorable, General Under Honorable Conditions

Section 7 of 14

Method of Qualification (Item 6)

Check all that apply.

Completed Appropriate Training Experience Representing Claimants

Section 8 of 14

Organization You Will Represent (Item 7A-7C)

Name of Organization Which You Will Represent (7A): *

Email at Organization (7B):

Phone Number at Organization (7C):

Section 9 of 14

Relationship to Organization (Item 7D)

Are you a member in good standing of the organization shown in Item 7A?

Yes No

Are you a paid employee of the organization shown in Item 7A, working for the organization for not less than 1000 hours annually?

Yes No

Section 10 of 14

County or Tribal Veterans Service Officers (Item 7E)

Are you a paid county or tribal employee: A) who works for the county or tribal government not less than 1000 hours annually; B) who has successfully completed VA-approved state training and examination; and C) who will receive regular state supervision and monitoring or annual training?

Yes No

Section 11 of 14

Other Accreditation (Item 8)

Are you accredited to any other organization(s)?

Yes No

Section 12 of 14

Federal Employment (Items 9A and 9B)

9A. Are you employed in any civil or military department or agency of the United States Government?

Yes No

9B. Have you ever held a federal government position which involved any action respecting claims in the Department of Veterans Affairs or the Veterans Administration?

Yes No

Section 13 of 14

Designee Certification (Items 10 and 11)

It is understood and agreed that neither the designee nor the organization will charge or accept any fee or gratuity for services rendered a claimant; that neither will publish or divulge any confidential information except as provided by law or regulation; and that any breach of these conditions will be sufficient basis for revocation of accreditation.

Signature of Designee (type full legal name): * Typing your full name here acts as your electronic signature.

Date of Signature (Item 11): *

Section 14 of 14

Certifying Officer (Section II)

To be executed by the proper certifying officer of the recognized organization. Certification: the undersigned certifies that the designee is of good character and reputation, is qualified by training or experience to present claims, and that the foregoing statements are believed to be correct.

Recommendation:

We therefore recommend primary accreditation. We therefore recommend cross-accreditation based on the designee's accreditation. We therefore recertify the qualifications of this representative.

Signature and Title of Certifying Officer (Item 12):

Name of Organization (Item 13):

Address of Certifying Officer (Item 14):

Date of Signature (Item 15):

Designee Name

Home Address (Item 2A)

Business Address (Item 2B)

Branch of Service (Item 3)

Dates of All Active Service (Item 4)

Character of Discharge(s) (Item 5)

Method of Qualification (Item 6)

Organization You Will Represent (Item 7A-7C)

Relationship to Organization (Item 7D)

County or Tribal Veterans Service Officers (Item 7E)

Other Accreditation (Item 8)

Federal Employment (Items 9A and 9B)

Designee Certification (Items 10 and 11)

Certifying Officer (Section II)

Application Submitted

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