Veteran Questionnaire

Veteran Questionnaire
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail
example@example.com
Air ForceArmyCoast GuardMarine CorpsNavySpace ForceOther
Start Date of Service*

MonthDayYear
Date
End Date of Service*

MonthDayYear
Date
Honorable DischargeGeneral Discharge Under Honorable ConditionsOther Than HonorableDishonorable DischargeMedical SeparationOther
The requested information is intended to better assist you in your employment and training needs.

This information is provided on a voluntary basis and, in accordance with the law, will be kept confidential unless approval is granted to disclose necessary information for the coordination of services at the OhioMeansJobs Center. Refusal to provide the requested information will not subject you to any adverse treatment.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
What is your family income?
list annual gross income
What is your family size?
list number of members in your household
I give my approval for OhioMeansJobs Center staff, Jobs for Veterans State Grant staff, and partner agencies to exchange and disclose necessary information about me for services to be provided to me by all programs administered via the OhioMeansJobs Center and/or partner agencies. I attest that the information stated above is true and accurate, and understand that the above information, if misrepresented, or incomplete, may be grounds for immediate termination of services and/or penalties as specified by law.

sign with your computer mouse or with your finger
Signature*

Clear
Date*

MonthDayYear
Date
ODJFS CS | ODJFS DVOP | WIOA Staff | Education Partner
Should be Empty:

Veteran Questionnaire

The requested information is intended to better assist you in your employment and training needs.