First Name: Last Name: Street Address:

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City: State Zip:

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Email Address: Phone: Cell Phone

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Gender: Household income: Marital status:
Male Female
Single Married Divorced
    Separated Widow
Age Employment status Number of kids

What branch of service
did you serve?		 What unit were you in? How many years did you serve?
Do you identify your service with a specific Military Action and if so which one? Do you belong to any Veteran organizations? Do you belong to any other community organizations
Yes No
Please list them here:
 Yes No
Please list them here:
Do you seek any healthcare services from your local VA Hospital? What year did you enlist?  
Yes No
Would you describe their service as your
primary healthcare provider?
Yes No
 
What was your last rank?
Do you own or rent your dwelling?
Rent Own
Do you donate to charities?
Yes No         If so, what types of charities do you donate to?
Since retiring from the military, what activities do you engage in?
golf add hunting online buying traveling
tennis reading volunteering RV'ing
swimming running mail order buying recreational vehicles
bowling entertaining friends and family fishing other


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