Print and Mail to:                    Disabled Veterans Services  

                                                    Attention:  Mr. Glen E. Svensson

                                                    3205 Marine Drive

                                                    Pompano Beach, FL  33062

* Required Information

* First Name                    ____________________________________________

* Last Name                    ____________________________________________

* E-Mail Address:            ____________________________________________

* Address 1                     ____________________________________________

  Address 2                     ____________________________________________

* City                               ____________________________________________

* State/Province              ____________________________________________

* Country                         USA_______________Other: ____________________

* Zip Code                       ____________________________________________

* Home Phone                ____________________________________________

  Work Phone                  ____________________________________________

  Mobile Phone                ____________________________________________

* Education Level            ____________________________________________

   Degree/Major/Minor     ____________________________________________

* Military Status               ____________________________________________

*Military Branch               ____________________________________________

*Military Pay Grade         __________­__________________________________

* Years in Service            ____________________________________________

* Home of Record            ____________________________________________

* Date of Separation        ____________________________________________

*Degree of Disability        ____________________________________________