Registration

631- 651- 5471

Angels for Warriors Registration Form

ELIGIBILITY OF SERVICE

All service men and women are eligible to take advantage of all Angels for Warriors has to offer. Prior to any official referral or service, please e-mail, mail, fax or drop off a copy of your DD 214 Service 2 or Member 4, VA Rating decision Letter, Line of Duty (LOD) documents, MEB/PEB Narrative Summary, ERB or ORB document, or WTU orders.

For more information on Angels For Warriors, you can contact us by clicking here, email info@angelsforwarriors.org or call 631-651-5471.

Date:

CONTACT INFORMATION

First Name:

Last Name:

Address:

City:

State

Country

Zip:

Phone:

SSN or Last 4:

Email:

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Phone:

Marital Status: Single Single/Engaged Married Divorced Widowed Separated

Gender: Male Female

Date Of Birth:

Spouse Name:

Number of Dependents/Ages:

I am NOT in need of legal assistance

I am in need of legal assistance. I will provide proof of income. *To qualify for pro bono legal services, your income, based on proof of income provided must fall below 200% of current year's poverty level guidelines.

*Please scan and email or fax a copy of your DD-214 form and photo ID to info@angelsforwarriors.com or 631-651-5473. Your registration is NOT complete without this form.

Angels for Warriors Registration Form

CONTACT INFORMATION

SERVICE INFORMATION

OTHER INFORMATION