Veteran's Club Veterans Village

First Name *

Middle Name *

Last Name *

Date of Birth (use the calendar icon) * +

Race / Ethincity *

Gender *

Phone *

Email Address *

Preferred Contact Method *

Phone

Text

Email

Emergency Contact Name/Number *

Emergency Contact Relationship to you *

What Branch(es) of the Military did you serve in? *

Years of Service *

Rank *

Do you have a copy of your DD214 / NGB 22 available? *

Yes

No

Discharge Status *

Upload DD214/NGB22 Here (Member 4 or Service 2)

Do you qualify for Military Benefits? *

Yes

No

Unsure

Have you deployed to a Combat Zone or in support of Combat Operations? *

Yes

No

Deployment Locations *

Number of deployments *

What was your primary job after training (MOS)? *

Do you have a Certified Service Animal *

Yes

No

Do you have a vehicle? *

Yes

No

Make / Model / Color *

Plate Number *

State *

County *

Do you use tobacco / nicotine? *

Yes

No

Do you use alcohol? *

Yes

No

Do you have a history of addiction? *

Yes

No

Please describe your addiction history, *

Please list all prescribed medications *

Are you using any medications that are not prescribed to you? *

Yes

No

Please describe *

Have you every been convicted of a crime? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

Please describe. *

Have you ever been charged with or convicted of a sex related offense or are you on the sex offender registry? *

Yes

No

Have you ever been diagnosed with any mental health disorders? *

Yes

No

If so, what have you been diagnosed with? *

Are you currently employed? *

Yes

No

Company *

Occupation / Title *

Gross Monthly Salary (before taxes) *

Any other income? Amount per month. *

Street Address *

City *

State *

Zip Code *

Supervisor *

How long at this job? *

Are you homeless or facing homelessness? *

Yes

No

Do you have a mailing address? *

Yes

No

Mailing Address *

City *

State *

Zip Code *

Where are you currently residing? *

Please add any additional information that could be beneficial to the application process. *

Terms and Conditions *

You consent to receive communications from us electronically. We will communicate with you by e-mail or phone. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.

I hereby certify that I am at least 18 years of age. Applicant represents that all information given on this application is true and correct. Applicant hereby authorizes verification of all references and facts, including but not limited to current and previous landlords, employers, and personal references. Applicant hereby authorizes Veteran’s Club to obtain any and all Unlawful Detainer, Credit Reports, Telechecks, and/or Criminal Background Reports. Applicant hereby waives any claim and releases from liability any person providing or obtaining said verification or additional information. Please sign *

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