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* Indicates required question
Email
*
Your email
Name
*
Your answer
Are you service connected?
*
yes
no
If YES, list each condition you are service connected for and the percentage rating for each (please provide the actual diagnosis and diagnostic code for each service-connected condition):
Your answer
If YES, what is your overall % disability rating?
Your answer
If YES, list any conditions you have been denied (please provide the actual diagnosis from the previous rating decision/s):
Your answer
If NO, please list each condition that you complained about, were treated for and/or diagnosed for in service:
Your answer
If NO, do you have a pending claim?
*
Yes
No
Do you have a pending Appeal?
*
Yes
No
Do you have a copy of your DD 214?
*
Yes
No
What is your character of discharge?
*
Honorable discharge
General discharge
Other Than Honorable (OTH) Discharge
Bad Conduct
Dishonorable Discharge
What is/or was your MOS / Rate / Job classification?
*
Your answer
Do you have copies of any rating decisions?
*
Yes
No
Do you have copes of any service medical records?
*
Yes
No
Do you have copies of any military personal records?
*
Yes
No
Do you have copies of any compensation and pension exams?
*
Yes
No
List conditions that you were treated for in service:
*
Your answer
Also list any medications for any and all service connected conditions:
*
Your answer
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