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          Name: *
First Name Middle Initial Last Name
Date of Birth (MM/DD/YYYY): *
Address: *
Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code
Phone: *
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Area Code Phone Number
E-mail: *
Branch of Service: *
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Years of Service: *
Military Discharge Number?
What County is Your Military Discharge Recorded In?
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