VETERANS INTAKE FORM
Department of Labor - Office of Veteran Afffairs - PO Box 167, Concho, OK 73022 - 405.422.7724
Veterans Name
*
Date of Birth
*
Applicants Name {if Other Than Veteran)
Mailing Address
*
City
*
State
*
Zip
*
Physical Address
*
City
*
State
*
Zip
*
Phone
*
Cell
*
EMail
*
example@example.com
Marital Status
*
Married
Divorced
Widower
Single
Alternate contact person
*
Phone
*
Next of Kin
*
Phone
*
Military Service
Veteran
*
Yes
No
Service Status
Active Duty
Reserves/NG
Deceased
Deceased?
*
Yes
No
Date of Death:
Funeral Home:
What cemetery buried?
VA Headstone:?
Receive VA Burial Flag?
Yes
No
Who has flag?
CONFIDENTIALITY AND PRIVACY
The OVA staff respects the privacy of all veterans, and we hold in strictest confidence all information disclosed. No information will be communicated to any NON-Veteran Agency without written consent from the Veteran, EXCEPT, by court order in circumstances deemed necessary to avert at crisis.
Signature of Applicant
Clear
Date
-
Month
-
Day
Year
Date
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