THE STEADFAST PREMIER GROUP
Veteran Screening & Eligibility Application
SECTION 1 — APPLICANT INFORMATION
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Current Address:
SECTION 2 — MILITARY SERVICE DETAILS
Branch of Service (Select all that apply):
Army
Marine Corps
Navy
Air Force
Space Force
Coast Guard
National Guard / Reserve
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Dates of Service:
Highest Rank Held:
Upload DD214 or Proof of Service
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SECTION 3 — DISCHARGE STATUS
Please select your discharge type:
Administrative Discharges
Administrative Discharges
Honorable
General (Under Honorable Conditions)
Other Than Honorable (OTH)
Uncharacterized / Special Discharges
Uncharacterized / Special Discharges
Entry-Level Separation
Medical Discharge
Hardship / Dependency Discharge
Separation for Disability (Permanent / Temporary)
Punitive Discharges (Court-Martial Only)
Punitive Discharges (Court-Martial Only)
Bad Conduct Discharge (BCD)
Dishonorable Discharge
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SECTION 4— ELIGIBILITY & LEGAL QUESTIONS
1. Have you ever been convicted of a felony?
Yes
No
If yes, please explain:
2. Are you currently on probation or parole?
Yes
No
3. Are you currently registered as a sex offender?
Yes
No
If yes, provide details:
4. Do you have any other criminal convictions that may affect eligibility for housing or services?
Yes
No
If yes, describe:
5. Are you currently involved in any pending legal matters or court cases?
Yes
No
If yes, describe:
6. Are you currently receiving VA benefits?
Yes
No
If yes, select:
Disability Compensation
Pension
Education
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Housing/Loan
Healthcare
Housing/Loan
Healthcare
7. Do you have a service-connected disability?
Yes
No
If yes, %:
8. Do you have stable housing at this time?
Yes
No
Temporarily housed
Homeless / At risk
9. Are you currently employed?
Full-time
Part-time
Not employed
Disabled / Unable to work
SECTION 5 — BACKGROUND CHECK CONSENT
Do you authorize The Steadfast Premier Group to conduct a background check?
Yes
No
Signature:
Date:
-
Month
-
Day
Year
Date
SECTION 6 — PROGRAM NEEDS ASSESSMENT
Services Needed (Select all that apply):
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Transitional Housing
Emergency Support Services
Food / Hygiene / Essentials
Employment Assistance
Mental Health Support
Substance Recovery Support
VA Benefits Assistance
Financial Literacy
Transportation Help
Family Services
Other
PROGRAM ELIGIBILITY SUMMARY
Eligible:
Honorable
General (Under Honorable Conditions)
Medical / Disability
Entry-Level Separation
Hardship / Dependency
Eligible With Review:
Other Than Honorable (OTH)
Bad Conduct (case-by-case)
Past misdemeanors
Not Eligible:
Dishonorable discharge
Violent felony convictions
Sex offender registration
Active warrants
Refusal to consent to background check
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THE
STEADFAST PREMIER
GROUP
Housing with Honor. Built with Purpose.
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