Military Service Adjustment Application Form
Use this form to request a military service adjustment review and provide the information needed to evaluate your request.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Current Address
*
Military Service and Adjustment Request Details
Branch of Service
*
Please Select
Army
Navy
Air Force
Marine Corps
Coast Guard
Other
Service Status
*
Please Select
Active Duty
Reserve
National Guard
Veteran
Separated
Other
Service Dates
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Adjustment Requested
*
Supporting Information and Submission
Supporting Documents
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Preferred Contact Method for Follow-up
*
Phone
Email
Both
Submit Application
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