BASIC INFORMATION-REQUIRED FULL NAME: SOCIAL SECURITY NUMBER :- - TELEPHONE NUMBER INCLUDING AREA CODE: - - CELL PHONE NUMBER INCLUDING AREA CODE: (IF APPLICABLE) - - Street Address: Apartment or PO Box Number: City: State: Zip Code: E-MAIL ADDRESS: MILITARY HISTORY INFORMATION:-OPTIONAL PLEASE SELECT WHICH BRANCH OF SERVICE YOU WERE IN: Army Marines Navy Air Force Coast Guard Army Reserves Marine, Reserve Air Force Reserves Army National Guard State: Air National Guard State: WHEN WERE YOU INDUCTED INTO THE MILITARY? WHAT WAS YOUR RANK AT THE TIME OF DISCHARGE? WHAT WAS YOUR STATUS AT THE TIME OF DISCHARGE? WHEN WERE YOU DISCHARGED? MEDALS RECEIVED (IF ANY): PLEASE TELL US ABOUT YOUR SERVICE CONNECTED DISABILITY VA CLAIM INFORMATION-OPTIONAL HAVE YOU FILED A VA CLAIM? Yes No IF YES WHAT WAS THE DATE YOU FILED YOUR CLAIM: MONTH/YEAR / ARE YOU CURRENTLY BEING COMPENSATED? Yes No IF YES AT WHAT PERCENTAGE? % IF YES, PLEASE DESCRIBE:
PLEASE SELECT WHICH BRANCH OF SERVICE YOU WERE IN: Army Marines Navy Air Force Coast Guard Army Reserves Marine, Reserve Air Force Reserves Army National Guard State: Air National Guard State: WHEN WERE YOU INDUCTED INTO THE MILITARY? WHAT WAS YOUR RANK AT THE TIME OF DISCHARGE? WHAT WAS YOUR STATUS AT THE TIME OF DISCHARGE? WHEN WERE YOU DISCHARGED? MEDALS RECEIVED (IF ANY): PLEASE TELL US ABOUT YOUR SERVICE CONNECTED DISABILITY VA CLAIM INFORMATION-OPTIONAL
