VA Form - The Warrior's Journey®

Your VA Information

Providing us with some basic information about your military experience and VA history will help us expedite your case and provide the most prepared services possible. 

Name
Address
DId you serve in any of the following Gulf War Hazard Locaitons?
Iraq; Kuwait; Saudi Arabia; the neutral zone between Iraq and Saudi Arabia; Bahrain; Qatar; the United Arab Emirates; Oman; Yemen; Lebanon; Somalia; Afghanistan; Israel; Egypt; Turkey; Syria; Jordan; Djibouti; Uzbekistan; the Gulf of Aden; the Gulf of Oman; the Persian Gulf; the Arabian Sea; and the Red Sea.
Did you serve in any of the following Herbicide (e.g. Agent Orange) lcoations?
Republic of Vietnam to include the 12 nautical mile territorial waters; Thailand at any United States or Royal Thai base; Laos; Cambodia at Mimot or Krek; Kampong Cham Province; Guam or American Samoa; or in the territorial waters thereof; Johnston Atoll or a ship that called at Johnston Atoll; Korean demilitarized zone; aboard (to include repeated operations and maintenance with) a C-123 aircraft known to have been used to spray an herbicide agent (during service in the Air Force and Air Force Reserves).
Have you been exposed to any of the following?
Asbestos, SHAD, Mustard Gas, Radiation, or Contaminated Water at Camp Lejune.
Component
Have you served in a combat zone since 9/11?
Are you receiving military retired pay?
Did you receive military separation pay?