Client Prequalified Questionnaire
Once completed please allow 24 to 48 hours for a response
Veteran Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Which Branch(es) did you serve in? (IF Guard or Reserve please state in the box below next to years in service.)
Army
Marine Corps
Navy
Air Force
Coast Guard
Space Force
Other
How many years in service? (If more than one branch list them individually.)
Ex.) Marines: 2001 - 2005 Army: 2008 - 2016
Did you deploy?
Yes
No
Please list your MOS
Ex.) 42A - Human Resources Specialist
IF deployed: Please list where you deployed and the years at those specific location.
Are you currently serving?
Yes
No
IF still serving: When do you get out?
In 1 year or less
In 1 year(s) or more
N/A
IF Eligible: Please specify your BEST days to get in contact. On next box please specify a time:
Monday
Tuesday
Wednesday
Thursday
Friday
Other
Please specify time range and best method of contact for Initial communication
Morning
Noon
Evening
Phone
Email
Text
Do you have a current disability rating? IF so: What is your rating?
No
Yes
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Are you Service-Connected for any disabilities?
Yes
No
Not sure
Do you have any Active Claims pending with the VA.
Yes
No
Not Sure
Do you have access to your DD 214?
Yes
No
Not sure
What was the character of your discharge?
Ex.) Honorable, Under Honorable Condition
Submit
Should be Empty: