Client Intake and Authorization Information
Still Serving Veterans will use this information to better serve the client. It will be retained in our database and may be shared with employers on an as-needed basis when requested by the client.
Sign in to Google to save your progress. Learn more
Email *
Full Name - Please enter full name *
Name You Go By
Email Address *
Mobile Phone Number *
LinkedIn Profile Address 
(Copy/Paste URL from the address line in your browser)
Home Address - Street, City, State, Zip *
Preferred Communication (Check all that apply)
How can we help you? (Services Requested) *
Required
Are you already working with a counselor or office or do you have a preference? *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Race/Ethnicity (Please Choose One) *
Duty Status *
Military Service *
Our sponsors require us to  have a DD214 on file that shows your Honorable discharge (or your military sponsor if you're a spouse). You may black out the SSN or we will do it when we receive it. We will not share your DD214 without your expressed permission. If you have not yet been discharged, a copy of your most recent FitRep/Perf Rev may be provided. *
Protected Veteran Status? *
Required
Current Employment Status
Active Security Clearance Level?
Grade/Rank *
Retirement/ETS date *
MM
/
DD
/
YYYY
Type of Discharge *
Highest Level of Education
Schools you graduated from. (For High School - List name of High School, City and State, Year graduated; For College - List degree program, University Name, Location, Month/Year Completed)
Professional Organization you belong to? Fraternity, sorority, NIA, USACA, AUSA, SHRM, etc.
Civilian Certifications
Preferred Job Location?
Desired Career Field or Position/Title?
How did you hear about us? (Lead Source) *
Have you registered at RecruitMilitary.com/job-seekers *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Still Serving Veterans. Report Abuse
Google Forms