Veteran Request Form

Today's Date

Personal Information

First name

Last name

Birthday

Mobile Phone

Alt. Phone H/W:

Country/Region

Address

City

Zip / Postal code

Driver's License Number

DL Expiration Date

Last 4 digits of SSN:

How many members are there in your household (including yourself)

Please list relation, name and age for each household member.

Employment

Are you currently employed?

Company name

Address

How long have you worked there?

Are you requesting funds from Revitalizing Veterans' Dreams?

Amount of Funds Requested:

Reason for Funds Request:

Additional Information

Are you a veteran of combat?

Do you have PTSD?

If yes, how long have you been dealing with symptoms?

Are you using alcohol or drugs?

Any past treatment?

Treatment Type:

Inpatient

Outpatient

What recovery groups have you been a part of or are currently in?

Are you connected with your VSO?

If no, are you willing to apply for services?

Name of your VSO:

Are you a member of a local VFW or American Legion?

If yes, where at?

Are you willing to volunteer with Revitalizing Veterans' Dreams?

Have you received help from Revitalizing Veterans' Dreams in the past?

Please read and sign below:

Revitalizing Veterans' Dreams is not able to provide funds for rent, mortgage, or car payments. We help fill in the gaps/find temporary help until you are able to get the resources you need. A one on one intake interview is required to receive help from Revitalizing Veterans' Dreams. Failure to comply will result in a denial of your request.

I understand that by signing my name below I am releasing my personal information to Revitalizing Veterans' Dreams. This information will only be used to process my application and will not be shared with others.

Signature