Pacific Northwest Veterans Alliance Assistance Application

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Pacific Northwest Veterans Alliance Assistance Application

Please fill out the application below.

Email pnwveteransalliance@gmail.com or call (541) 701-8006 for any questions. All assistance requests will be reviewed by the Pacific Northwest Veterans’ Alliance Board of Directors. Unfortunately, not all requests will be granted. We appreciate you submitting your request and we will be in contact with you soon.

Email *

Full Name *

Date of Birth

YYYY

Is this request for you or a veteran you know?
*

For Me (I am the veteran)

For a veteran I know

Address, City, Zip & State (please put N/A if you are not currently housed) *

Phone Number *

Demographic Questions

At Pacific Northwest Veterans Alliance, we strive to provide effective and tailored assistance to meet the diverse needs of our community. To better understand and address those needs, we kindly request you to share some demographic information. Your responses will be kept confidential and used solely for the purpose of assessing and improving our services. It's important to note that the answers to these questions are not used for eligibility for services. Thank you for helping us serve you better.

Ethnicity *

White / Caucasian

Hispanic or Latino

African American

Asian

Native American / American Indian

Native Hawaiian or Pacific Islander

Other / Unknown

Other:

Education *

Less than a high school diploma

High school degree or equivalent

Associate's Degree

Bachelor's Degree

Master's Degree

Doctorate

Trade School

Other:

Employment Status *

Employed Full-Time (40 + hours a week)

Employed Part-Time (less than 40 hours per week)

Unemployed (currently looking for work)

Student

Retired

Self-Employed

Marital Status *

Single

Married

In domestic partnership

Divorced

Widowed

Annual Household Income *

Below $10k

$10-$20k

$20 - $30k

$30-$40k

$40-$50k

$50-$60k

$60-$70k

$70-$80k

Over $80k

Other:

Assistance Requested *

Do you have a cost estimate for request? *

Are there any other organizations that have already been contacted to help with this request? If so, who and what support has been offered?
*

Were you referred to us, if so, by who? How did you hear about our organization? *

Has Pacific Northwest Veterans’ Alliance assisted you or a family member in the past?
*

Yes

Any other details you can share about this request or the person needing assistance that would help us as we review this application?
*

Branch of Military Service (proof of service will be required) *

Dates Served *

Please email a copy of DD214 to pnwveteransalliance@gmail.com

Submit

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