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First Name:
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Middle Name:

Last Name:
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Address:

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City

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Zip

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Phone:
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Email:
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Date of Birth (mm/dd/yyyy):
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Last 4 SSN:

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Military Branch:
Era of Combat:
Type of Discharge:
Sex:

Current Compensation Rating:

Special Recognition (ctrl click for multiple selections):

Special Medical Instructions and/or Medical/Psychological Diagnosis (160 character limit):
Military History (Your Hometown, High School, College, Military Training.  Please provide details.) [See Example]:

How will you send your document(s) for verification of military service?:

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I give permission to USVCP to allow my military service to be verified online:

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Emergency Contact Name:

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*PLEASE READ:  Verify your data fields to ensure that information is accurate.  USVCP is not liable for inaccurate, misleading, or erroneous data entries.