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SCG VETERAN INTAKE FORM
First Name
*
Last Name
*
Email
*
Address
*
Phone
*
Are You Currently Experiencing Homelessness or in Danger of Becoming Homeless?
*
Alternate Contact First and Last Name
Alternate Contact Phone Number or Email Address
Marital Status
*
Military Branch
*
Date Entered Regular Active Duty Service
*
Month
Day
Year
Date Separated from Regular Active Duty Service
*
Month
Day
Year
If Currently Active Duty, What is Your Projected Retirement/Separation Date?
Were you Deployed Overseas After August 2, 1990?
*
Indicate the Locations You Were Stationed.
*
Type of Discharge
*
Have you Ever Filed a VA Disability Claim?
*
If So, What Is Your Combined Disability Rating?
*
Are You Currently Employed? If Yes, How Many Hours Per Week?
*
How Did You Hear About Us?
*
Personal Referral
Google Search
VA Website
Case Manager Referral
SCG Presentation
Personal Referral-If Someone Referred You, Please Let Us Know Who to Thank.
SUBMIT
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