Veteran's First Request Form Thank you for your interest in the JVS SoCal. (*indicates a mandatory field) First Name* Last Name* Last 4 of your SSN* Date of Birth* Age number* age Email Address* Home Phone Number* Mobile Phone Number What is your preferred method of contact —Please choose an option—PhoneEmailText Street Address City State ZIP Code* Military Affiliation* —Please choose an option—ActiveReserveSpouseVeteran How did you hear about JVS Veteran's Program? Active US Military Service Begin Date* Active US Military Service End Date* Branch of Service (Select all that apply*)Air ForceArmyCoast GuardMarinesMerchant MarinesNational GuardNavy Rank* —Please choose an option—E-1E-2E-3E-4E-5E-6E-7E-8E-9O-1O-2O-3O-4O-5O-6O-7O-8O-9O-10W-1W-2W-3W-4W-5 Military Occupation Type of Discharge* —Please choose an option—HonorableGeneral under honorableOther than honorableBad conduct dischargeBad conduct dischargeDishonorable dischargeEntry-level separation Era(s) of Service*Iraq/Afghanistan (9/11/2001 - Present)Gulf War I (8/1990 - 9/10/2001)Post Vietnam (1976 - 7/31/1990)Vietnam (1964 - 1975)Post Korean (1956 - 1963)Korean (1950 - 1955)Post WWII (1946 - 1949)WWII (1941 - 1945)Other Highest Level of Education —Please choose an option—ElementaryHigh School/GEDSome college/Technical trainingAssociate's DegreeBachelor's DegreeMaster's degree or higher Ethnicity —Please choose an option—African American/BlackAmerican Indian/ANAsian/PAIHispanic/LatinoMulti-ethnicWhite/CaucasianOther Citizenship* —Please choose an option—US CitizenAuthorization to work in the USPermanent Resident Employment Status* —Please choose an option—EmployedNot EmployedEmployed with noticeTermination/Military Separation Number of weeks unemployed* What Career Field(s) of employment are you seeking at this time*Administrative/ClericalConstructionCustomer ServiceEducationEntertainmentFinance/AccountingGovernmentHealthcareHospitalityHuman ResourcesITJanitorial/MaintenanceLaw EnforcementLogisticsNon-ProfitProject ManagementSecuritySkilled LaborTransportationOther If you have selected Other, please enter Other Career Field Do you have a Service Connected Disability Rating?* —Please choose an option—YesNo If so, what is your disability rating? —Please choose an option—0%10%20%30%40%50%60%70%80%90%100% Are you receiving public assistance? —Please choose an option—YesNo Do you need Housing Assistance? —Please choose an option—YesNo Do you have Reliable Transportation? —Please choose an option—YesNo
