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2. Please complete all required fields
   Appointment requests will be responded to within 2 business days (Monday-Thursday).
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Secondary Phone Number
16. Email Address
18. Branch of Service*
19. Dates of Service
21. Provide need/reason for appointment request:
23. Benefit Type Requesting*

    Please select the benefit(s) you are requesting an appointment for.

    1. VA Disability Compensation
    2. VA Disability Pension
    3. VA Medical Care
    4. VA Home Loan Guaranty
    5. VA Life Insurance
    6. GI Bill
    7. Vocational Rehabilitation
    8. Appeals
    9. Burial/Memorial Services
    10. Military Records & Medals
    11. Discharge Review/Correction of Military Records

    1. Vet Center Readjustment Counseling
    2. Tricare
    3. ChampVA
    4. Military Retirement Benefits
    5. Dependent Education Assistance
    6. Surviving Spouse/Dependent Benefits
    7. Emergency Financial Assistance
    8. State Veterans Homes
    9. Individual Veteran Benefit Briefing
    10. Presentation on Veterans Benefits to a Group or Association
    11. Other
25. Have you ever filed a VA Claim?*

    1. Yes
    2. No
    3. Unsure
26. Are you a Washtenaw County Resident?*

    1. Yes
    2. No
    3. Unsure
28. Appointment Availability*
    Appointment Availability Start Date

    Appointment Availability Start Time

    —

    Appointment Availability End Date

    Appointment Availability End Time
    Please indicate two times you are available for an appointment. We typically schedule appointments in the afternoons starting at 1:00pm Monday through Thursday, closed on Fridays. We will try our best to accommodate your request to the best of our abilities. Not all time requests are guaranteed.
30. Additional Remarks
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

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