Veterans Court Referral Form

Fields marked are required.

Name

Email:

DOB:

SSN

Street Address

Apt / Suite / Other

City

State

ZIP

Home PhoneNumber

Work PhoneNumber

Cell Number

Translation services required

If yes, what type of services

Race/Ethnicity

If other, please explain:

Sex

If other, please explain:

Branch of Service

Date of Separation

Honorable discharge

If other, indicate type of discharge:

Current legal charge(s):

Currently incarcerated

If yes, where?

Arrest date

Currently on Probation

If yes, where?

Probation charge(s):

Name:

Relationship to Defendant:

Phone:

Email: