APPLICATION FOR VETERANS CREDIT

 

MADISON COUNTY DEPARTMENT OF PERSONNEL/CIVIL SERVICE

PO BOX 636

WAMPSVILLE, NEW YORK 13163

Telephone:  (315) 366-2341

Web Site:  madisoncounty.org

 

Answer every question completely, instructions are on the back.  Print or type only.  Not valid unless accompanied by discharge document (see C on page two).

 

1.  Examination title and number:                                                                                                                      

 

2.  Name:                                                                                            

 

     Mailing address:                                                                  

 

                                                                                                           

 

3.  Social Security and/or Service Serial Number:                                                   Birth date:                           

 

4.  Dates of Active Service:    From                                                      To                                                       

 

5.  Credit Claimed (check one)              Non-Disabled Veteran

                                                   

                                                             Disabled Veteran                                 V.A. Claim Number

 

Have you sent Authorization for your Disability Record to the V.A.?      Yes                  No

 

6.  Present Legal Address:                                                                   

                                                   Street Address

 

                                                                                                                       

                                                   City, State, Zip

 

7.  List ALL your public service employment since January 1, 1951.  Attach additional sheets if necessary.

 

DATES		Employer Name and Address	Title of your position	Veterans Credit used
From	To			Yes	No

 

8.  I declare, subject to the penalties of perjury, that the statements made on this form and any attachments are to the best of my knowledge true and correct.

 

                                                                                                                                               

Signature                                                                                              Date

 

 

 

READ AND FOLLOW INSTRUCTIONS CAREFULLY

 

A.  In order that your application for additional credit as a veteran can be processed, follow the instructions below.  Failure to follow these instructions completely may result in restriction on the eligible list.  Please give this your immediate attention since Veterans’ Credit cannot be granted after the eligible list has been established.

 

1.   Answer all questions on page 1 of this form, attach documentary proof of your eligibility as specified under C below and mail to the Madison County Department of Personnel/Civil Service.

 

2.   Complete the enclosed Disability Record Authorization in duplicate and forward the Authorization immediately to your Regional Office of the United States Department of Veterans Affairs.

 

B.  ELIGIBILITY REQUIREMENTS

 

1.   Honorably discharged or separated from the Armed Forces of the United States.

 

2.   Active duty in the Armed Forces of the United States during any of the following periods:

 

(a)     December 7, 1941 to December 31, 1946; June 27, 1950 to January 31, 1955; December 22, 1961 to May 7, 1975; Persian Gulf-August 2, 1990 to the date upon which such hostilities end.

 

 

(b)     U.S. Public Health Service:  July 29, 1945 to December 31, 1946 or June 27, 1950 to July 3, 1952.

 

(c)     The Armed Forces expeditionary medal, Navy expeditionary medal or Marine Corps expeditionary medal for Hostilities in Lebanon:  June 1, 1983 to December 1, 1987; Hostilities in Grenada:  October 23, 1983 to November 21, 1983; Hostilities in Panama:  December 20, 1989 to January 31, 1990.

 

3.   If since January 1, 1951, you used your veterans’ credits for permanent appointment or promotion in New York State or its civil divisions, you may not claim them again.

 

C.  ACCEPTABLE DOCUMENTARY PROOF – Report of Military Separation:

 

Report of Separation and Honorable Discharge and/or Certificate of Service.  Acceptable military forms NAVPERS-553; NAVMC-78 PD; WDAGO-53, 98; DD 214.  If your name is different from that shown on your Report of Separation and Honorable Discharge and/or Certificate of Service, include a marriage certificate or other legal document to verify the change.

 

NOTE:  Any of the documents listed above, either the original or photocopy, will be considered as satisfactory evidence for each requirement.  Original documents will be returned after your application has been processed.  Photocopies are preferred.