Eligibility Form

First Name
Last Name
Email
Phone
Branch of Service: –None– Army Air Force Marine Corps Navy Coast Guard Space Force
Rank at Separation:
Have you previously filed a claim?: –None– Yes No
Results of your claim:
Current VA disability rating: –None– 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Type of Discharge: –None– HON – Honorable GEN – General (under honorable conditions) OTH – Other than Honorable BCD SPCM – Bad Conduct Discharge awarded at a Special Court-Martial BCD GCM – Bad Conduct Discharge awarded at a General Court-Martial DD – Dishonorable Discharge E – Eligible NE – Not Eligible A – Eligible only if determined not dishonorable
Do you have a DD-214?: –None– Yes No
Office use only – Veterans Rep: