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VIFORM
Alison Boisvert
2023-04-21T10:33:58-04:00
VETERAN INTAKE FORM
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Name
*
First
Last
City/Town
Phone Number
Email
*
Please enter your email, so we can follow up with you.
Branch of Service
Date of Entry
Date of Discharge
(Check off all applicable categories below)
Service Connected Disability or pending claim with V.A.
Vietnam Era, period beginning February 28, 1961 and ending May 7, 1975
Homeless or at risk of homelessness
Fleeing or attempting to flee hostile housing situation
Between the ages of 18 and 24
Exited the military within the previous 12 months, and have been unemployed for 27 + weeks (cumulative)
Previously incarcerated and require assistance overcoming barriers resulting from arrest or conviction
Lack a High School Diploma or GED (HiSet)
Receiving MA CH 115 benefits
Low income based on chart below:
Transitioning Service Member
Spouse of a military member or former military member who, a) Died from service connected injuries, b) KIA/MIA, c) 100% disabled
None of the above apply to my current situation
Would like to speak with a Veterans Representative
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