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Name First Last Address* Street Address City StateAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Military Affiliation (Choose from drop-down)*VeteranCurrently ServingFamily MemberWe will contact you for a copy of your DD-214 to verify your veteran status.Military Service (Choose from drop-down)*ArmyAir ForceCoast GaurdMarine CorpsNavyMilitary Status (Choose from drop-down)*Active DutyNational GaurdReservesRetiredSeparatedGender*MaleFemaleMarital Status*MarriedSingleBirthdate* Date Format: MM slash DD slash YYYY Current Living Conditions*YesNoEmployment*YesNoPhysical Health Issue*YesNoMental Health Issue*YesNoFinancial Issues*YesNoEducation*YesNoFamily Support*YesNoPeer Support*YesNoTransportation*YesNoVeteran Benefits*YesNoLegal Matter*YesNoVolunteer Opportunities*YesNoOther
