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1
Applicant Information
2
Spouse Information
3
Veteran or next of kin if Veteran is deceased
4
Documents
Veteran Applicant
1. First Name
*
*
2. Middle Name (or Initial)
*
3. Last Name
*
*
4. Suffix
*
5. Date of Birth
*
*
5. Place of Birth
*
*
6. Social Security Number
*
*
7. Marital Status
*
MARRIED
NEVER MARRIED
SEPARATED
DIVORCED
WIDOWED
8. Gender
*
MALE
FEMALE
9. Military Status
*
ACTIVE DUTY
NATIONAL GUARD
RESERVE
RETIRED
VETERAN
10. Branch of Service
*
AIR FORCE
ARMY
COAST GUARD
MARINE CORPS
NAVY
SPACE FORCE
OTHER
11. War Service
*
AFGHANISTAN
IRAQ
KOREA
PEACETIME
PERSIAN GULF
VIETNAM
WWII
OTHER
12. Service Number
*
*
13. Highest Rank Attained
*
*
14. Last Name on DD-214
*
If different than above Last Name
PERIOD(S) of Active Duty Military Service or National Guard/Reserve Service
15a. Entry Date
*
*
15b. Entry Place
*
*
16. If Retired Military (Active or Reserve) Date of Retirement
*
15c. Discharge Date
*
*
15d. Discharge Place
*
*
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