Blaster Program Application

Note:

YOU MUST BE A CURRENT VETERAN IN THE O.C.B. PROGRAM PARTICIPATING REGULARLY IN SUNDAY SHOP DAYS or LIMA CHARLIE VETERAN PEER SUPPORT GROUP PARTICIPATING IN THERAPY AT LEAST 16 HOURS A MONTH WITH THE REST OF THE TEAM TO QUALIFY FOR THIS PROGRAM. EACH APPLICATION WILL BE REVIEWED FOR ACCEPTANCE AND AVAILABILITY OF RESOURCES BY THE BLASTER PROGRAM TEAM. PLEASE NOTE THAT SINCE WE ARE ENGAGING WITH THE GENERAL PUBLIC FOR ASSISTANCE THAT PROJECTS WILL TAKE TIME TO LOCATE RESOURCES AND SOLUTIONS TO EACH INDIVIDUALS NEEDS AND AS SUCH WE MAY NOT BE ABLE TO ASSIST. We will try our best !
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Branch of Service*

ArmyNavyMarine CorpAir ForceCoast GuardSpace ForceArmy National GuardAir National Guard
Which O.C.B. location do you regularly participate in therapy?*

Indiana-01Alabama-01
Phone Number*
What Date did you start participating in OCB Programs?*

YearMonthDay
Date
Approximately how many hours would you say you have in OCB programs per month?*
must be 16 hours or greater
Vehicle Information
VIN
Vehicle Type
Year
Make
Model
Type of assistance needed*

A vehicle to get me from A to B (beater with a heater)I just need help getting the vehicle I have fixedOther
Details on what is wrong with your vehicle or information on how we can assist you*
On a scale of 1 star is a frowny face to a 5 star being a smiley face what would you say your experience with OCB has been?
Should be Empty:

Note:

Vehicle Information