Welcome

1
Name Please enter your first and last name as it appears on your military ID or DD214
First Name
Last Name
2
AddressYour physical address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Phone Number Active Phone number where you can be reached
Please enter a valid phone number.
4
Email Active email for communicating with Veterans Aid Network
example@example.com
5
Date of BirthPlease include month, day and year
6
Service Branch Please specify the branch of service you served in
7
Dates of Service Please provide the entry and discharge dates of your service
8
Status Are you a veteran?
YESNO
9
VA Disability Rating If you are currently receiving VA Disability Benefits, please specify the percentage below.
10
Explanation If you do not receive VA Benefits, please explain why below and if you have applied for benefits or not. If you are receiving benefits, please write "NA" and move to the next question.
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Ok
11
How did you hear about us? Please specify below
12
Assistance Request Please describe your situation in detail and what assistance you are asking for below.
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Ok
13
Amount Requested If applying for emergency or financial assistance, what is the amount you are requesting?
14
Other Assistance Have you received any other type of assistance within the last 90 days?
YESNO
15
Explanation If you have received assistance within the last 90 days, please explain below. If not, please write "None" and move to the next question.
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16
Additional Information Is there anything else we should know in order to assist you more effectively?
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Ok
17
VerificationAre you able to send copies of your DD214 and Military ID for verification?
YESNO
18
AcknowledgementBy submitting this application, you agree to allow Veterans Aid Network to use the information provided to assess your needs and connect you with the appropriate services and resources. All personal information is confidential and will not be shared without your consent. By clicking YES below, you affirm that all information provided is accurate to the best of your knowledge. You understand that your electronic signature is legally binding and is considered the same as a handwritten signature for the purpose of this application. You also agree to have your information verified by Veterans Aid Network or our third party verifiers to make sure all information provided is accurate.
YESNO
19
Electronic Signature Your typed name below is your electronic signature and is legally binding and considered the same as a handwritten signature for the purpose of this application.
20
Social Media Consent FormThis consent form ("Agreement") is made and entered into as of the date entered below by the undersigned individual ("Participant"), granting permission to Veterans Aid Network ("Organization") to use their information, images, and/or statements for promotional and public disclosure purposes. By typing your name below, you hereby authorize Veterans Aid Network to use, reproduce, and publish your name, photographs, video recordings, testimonials, and any other relevant information provided for the purposes of: Social media posts (Facebook, Instagram, TikTok, LinkedIn, YouTube, etc.), Website Content and promotional materials, Newsletters, press releases, and marketing campaigns, any other lawful public disclosures related to the Organization's mission. You understand that your information may be used to promote awareness, highlight the Organization's impact, and support its fundraising efforts. You acknowledge and agree that you will not receive any compensation for the use of your information. The Organization may edit, modify, and adapt the materials for clarity and promotional purposes. You voluntarily consent and have the right to revoke that consent at any time by providing written notice to the Organization. However, revocation will not apply to materials already published. WAIVER OF LIABILITY: You release and hold harmless Veterans Aid Network, its employees, representatives, and affiliated organizations from any claims, damages, or liabilities related to the use of your information as authorized by this agreement. ELECTRONIC SIGNATURE DISCLOSURE: You agree that your typed name below serves as your electronic signature, carries the same legal effect and validity as a handwritten signature. You acknowledge that by electronically typing your name on this document, you are consenting to be legally bound by its terms, just as if you had signed a paper copy in person. CONSENT ACKNOWLEDGEMENT: I have read and fully understand the terms of this Consent Form. By typing my name below, I voluntarily agree to the use and disclosure of my information as outlined above.
Typed Name
Date
21
Please take a moment to fill out our Financial Form and upload your supporting documents. When done, please click YES below and submit your form. The link to our Financial Form is below:https://form.jotform.com/250487204237152
YESNO
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