Intake – VetPDC

You made our great Nation a priority,
Let us make you our priority.

veteran intake form

4922 Bill Gardner Pkwy # 252
Locust Grove, Georgia 30248

Fax: 815-344-2441
Email: info@vetpdc.com

VetPDC Intake

First Name

Middle Name

Last Name

Date of Birth

Place of Birth

Last Four of SSN/Claim #

Branch of Service

Sex

Address

Most Recent Active Service Date Start (MM/DD/YR)

Most Recent Active Service Date Finish (MM/DD/YR)

Service Entrance Location

Service Discharge Location

National Guard

Reserves

Obligation Term of Service (MM/DD/YR)

MOS/AFS C

Type of Discharge

Type of Disabilities and their Percentages

Disabilities you With to Claim, Reopen, or Increase

Best Time of Day to Contact You

Preferred Contact Method

Referred by

Additional Notes