Survey - Request Application for New, Specially-Adapted Home Program

*1.

Question - Required - Are you currently on Active Duty; in the Reserves; or have you been honorably discharged from the U.S. Armed Forces? Active-Duty
Reserves
Honorable Discharge

*2.

Question - Required - Branch of Service

*3.

Question - Required - Rank/Grade

*4.

Question - Required - First Name

*5.

Question - Required - Last Name

*6.

Question - Required - Home Phone

7.

Question - Not Required - Cell Phone

*8.

Question - Required - Mailing Address (Address where you currently get your mail)

(Maximum response 255 chars, approx. 5 rows of text)

*9.

Question - Required - City

*10.

Question - Required - State

*11.

Question - Required - Zip Code

12.

Question - Not Required - Email (Must be a valid email address)

*13.

Question - Required - Brief description of injuries and how they were sustained

*14.

Tell us about yourself:

(Select one of the available choices or enter a different value.)
Question - Required -

15.

Question - Not Required - If you are requesting information on behalf of the injured service member, please provide us with your contact information. Name, Phone, Email and Organization you are affiliated with.

*16.

Question - Required - How did you hear about Homes for Our Troops?
Please make at least 1 selection from the choices below.

	Referred to by a friend
	At hospital
	TV
	Newspaper
	Radio
	Magazine
	Brochure
	Event
	Internet search
	Other

*17.

Question - Required - Where do you want to reside? (City, State, County) Please be as specific as possible.

Please contact our Intake Coordinator, Laura Butler if you need help in determining your eligibility. vetinfo@homesforourtroops.org or 508-823-3300