Military Eligibility Form

Please take a moment to fill out this military specific questionnaire

First Name *

Last Name *

What Branch(s) have you served in? *

Law Enforcement

Fire/EMS

US Military

Other

Servce Status *

Actively Employed / Active Duty
Retired / Discharged
Medical Leave
Other
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End Date of Service (if applicable)

Final Discharge Reason *

Active
Administrative
Bad Conduct Discharge
General Under Honorable Conditions
General Under Other than Honorable Conditions
Honorable Discharge
Unknown
Uncharacterized
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Have you served in any imminent danger areas? *

Yes

I incurred... *

A visible or invisible injury, illness, or wound.

Was not injured or do not remember when injuries occurred

Has a chronic injury/illness and does not have a specific date of injury.

Other

Military Eligibility Documentation

In order to confirm your eligibility for WRP services, we ask that you submit the most recent copy of one or more of the below documents based on your status. Additional information or documentation may be needed to confirm eligibility.

1. Discharged or Retired (Final or Most Recent Documents Showing Dates & Discharge Status)

DD214 (showing discharge status)

NGB22 (National Guard)

DD256 (Reserves)

Discharge or Retirement Orders/Certificate (Reserves)

VA Benefits Summary Letter (includes Date of service and character of discharge)

2. Active Duty

MEB/PEB Narrative Summary

Current Unit Orders to a WTU/WTB as patient (not cadre)

Line of Duty (LOD) Form with Memo

Service/Personnel Record (ERB/ORB/BIR/SURF/EPR/etc.) Dated within the last 90 days.

Other official documents verifying eligibility will be considered on a case-by-case basis.

Military Eligibility Documentation *

Upload Eligibility Documentation