Intake Form Please Fill Out The Form Below A member of our Bravo Foxtrot team will be in touch shortly This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.About YouName(Required) First Last Address(Required) Street Address Address Line 2 City ZIP Code Email Address(Required) Email Address Confirm Email Address Phone(Required)DOB(Required) MM slash DD slash YYYY Last 4 Digits of Social Security Number(Required)Please enter a number from 1000 to 9999.Branch of Service(Required) Navy Army Air Force Marine Corp Coast Guard Rate OR MOS(Required)Date of Entry(Required) MM slash DD slash YYYY If you do not know the day, please choose the 1st of the month. Date of Discharge(Required) MM slash DD slash YYYY If you do not know the day, please choose the 1st of the month. Discharge Characterization(Required) Honorable General Under Honorable Other Than Honorable Administrative Separation Bad Conduct Discharge Dishonorable Discharge Medical Discharge Rank at Discharge(Required)If different, highest rank achieved.List all Duty Stations and Deployments(Required)How Can We Reach You?We would love to talk with you. How can we get in touch?Preferred Method of Contact(Required)EmailPhoneUpload DD-214 and State Issued Photo ID Drop files here or Select files Max. file size: 50 MB. Please make a copy of your DD–214 and blank out your SS# on it, then upload this copy to us.How can we help you?Your Comments/Questions(Required) ARE YOU A VETERAN? Bravo Foxtrot United Veterans Inc. offers aid to traumatized veterans that have been forgotten by the system, and by society. Contact Us 631-356-9245 info@bravofox.org FollowFollowFollow
