Veterans Employment Eligibility Screening Form

Your Contact Information

First Name

Middle Initial

Last Name

Preferred Name

County

Street Address

City

State

ZIP

Phone Number

Email

How would you prefer to be contacted?

Phone

Email

Military Service Dates

Start Date

End Date

Current Service Member Questions

Current service members may already be eligible for Veterans Employment Services.

You may already be eligible if any of the following circumstances apply to you:

You are currently receiving medical treatment for a wound, illness, or injury at a military treatment facility or in a Warrior Transition Unit.
You are within one year of separation from active duty or two years of retiring and have participated in any portion of the Transition Assistance Program (TAP).
You are a member of the National Guard or Reserves and were activated during a recognized period of conflict or campaign.

Do any of the circumstances listed above apply to you?

Yes

No

If your answer is "No," we will ask some additional questions to determine your eligibility.

Veteran Questions

Have you served on active duty for more than 180 consecutive days and were discharged with other than a dishonorable discharge?

Yes

No

Were you released from active duty due to a service-connected disability?

Yes

No

Have you been discharged or released from active duty due to a “Sole Survivorship”?

Yes

No

Are/were you a member of the National Guard or Reserves and were activated during a recognized period of conflict or campaign?

Yes

No

Spouses and Caregivers Questions

Are you a spouse or family caregiver of a wounded, ill or injured service member who is receiving care at a military treatment facility?

Yes

No

Are you a surviving spouse of a veteran who passed away due to a service-connected disability?

Yes

No

Are you a spouse of a veteran who has a total and permanent service-connected disability?

Yes

No

Are you a spouse of a veteran who has been listed as ‘MIA’, captured in the line of duty by a hostile force, or forcibly detained by a foreign government or power, for more than 90 days?

Veterans Employment Eligibility Screening Form

Instructions and Data Privacy

Service Member Relationship

Your Contact Information

Military Service Dates

Current Service Member Questions

Current service members may already be eligible for Veterans Employment Services.

Veteran Questions

Spouses and Caregivers Questions

Qualifying Circumstances Questions

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