Veteran Registration Form Name* First Last Gender* Male Female Social Security or Military ID Number* Date of Birth* MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Email PhoneEmergency Contact First Last Emergency Contact Relationship Emergency Contact PhoneHave you attended a Stand Down before?* Yes No If yes, where and when?Marital Status* Married Widowed Divorced Separated Never Married Employment Information* Employed Unemployed Retired Disabled Are you receiving any income* Yes No What do you believe is limiting your ability to become employed?* Education Experience Disability Transportation Criminal Record Child Care Drug Use Other *Other Reason Ethnicity* African American Asian American Native American Hispanic Caucasian Other *Other Ethnicity Housing* Homeless Living in a Shelter Renting Homeowner On the verge of becoming homeless Living with a Friend/Relative Living in transitional housing If homeless, how long have you been homeless* 0-6 months 6-12 months 1-2 years 2-5 years 5+ years Branch of Service* Entry Date MM slash DD slash YYYY Discharge Date MM slash DD slash YYYY Discharge* Honorable Other than Honorable Dishonorable Bad Conduct/ General Court Martial Don't Know Combat Theater / Service Era (Check as many as apply)* Peacetime 01/01/1947 06/26/1950 Korea 06/27/1950 01/31/1955 Peacetime 02/01/1955 08/04/1964 Vietnam 08/05/1964 05/07/1975 Peacetime 05/08/1975 08/01/1990 Desert Shield/Storm 08/02/1990 09/10/2001 OIF/OEF/OND 09/11/2001 Present Other Panama, Granada, Somalia, former Yugoslavia/Kosovo Are you currently enrolled in VA Healthcare* Yes No If no, why Which of the follWhich of the following VA benefits have you received or claimed. Please check all that apply* Education GI Bill, Post 9/11, GI Bill etc... Service Connected Disability Compensation Medical or Dental Care HUD/VASH Vocational Rehabilitation & Employment Pension Home Loan VRAP None Other Other services you would like to see at the next Stand Down. Check all that apply. Health Services Substance Abuse Services Legal Services Housing Assistance Mental Health Services Employment Assistance Veterans Benefits Counseling Other Desired ServicesRelease of Information (ROI) signed* Yes No Media Authorization Signed* Yes No DD214#* How did you hear about our Stand DownCommentsThis field is for validation purposes and should be left unchanged. Δ
