Fox Valley Veterans Council - New Applicant

Veteran's First Name (required)

Veteran's Middle Name

Veteran's Last Name (required)

Veteran's Date of Birth (required)

Number of dependents in household (required)

Please enter dependents' names and dates of birth

Veteran's Address (required)

Address 2

City

State AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming

Zip

County Select Value Calumet County Outagamie County Waupaca County Winnebago County Brown County Fond du Lac County Other

If 'Other' County, specify:

Veteran's Cell Phone Number Note: Please provide at least one method of contact.

Veteran's Home Phone Number

Veteran's Email

Preferred way to contact (required) Select Value Phone Email SMS Virtual

Branch of Service (required) Select Value Air Force Army Coast Guard Marines Navy Space Force Multiple Branches Guard/Reserve

Discharge Type (required) Select Value Honorable General Other than Honorable Bad Conduct Dishonorable Uncharacterized Don't know

How did you hear about the FVVC Veterans Emergency Fund? (required) Select Value 211/United Way 411 American Legion Aurora CVMA CVSO DVA DWD Feeding America FVTC FVVC Case Worker FVVC Client FVVC Website Heat for Heroes Hooah WI HUD-VASH Leaven LSS Mercy Online Pillars Police Self-Referral Theda Care Tri-County Dental TVSO Veteran Affairs Veterans Treatment Court VHRP WDVA/VORP Other

Can we share your information with other resources and partners that may also be able to assist you?
NOTE: Selecting "No" may delay or significantly limit or delay our ability to offer assistance (required) Select Value Yes No

Digital Rights Policy Agreement
I agree with the storage and handling of my data by this website and the Fox Valley Veterans Council, Inc. as listed below. (required) Select Value Yes I agree with the storage and handling of my data by this website as listed below. and the Fox Valley Veterans Council. Please read and learn more about our Digital Right's Policy linked at the bottom of our website. By submitting your personal information through this website, you acknowledge and agree that your data will be used solely for the stated purpose of responding to your inquiry or providing the requested services. We take reasonable measures to protect your information; however, no transmission of data over the internet can be guaranteed as 100% secure. We will not sell, share, or distribute your personal information to third parties without your consent unless it is in coordinating with additional resources, or partners, or if required by law. By using this site, you accept these terms and acknowledge the inherent risks of online communication. If you have any concerns, please contact us directly before submitting your information.

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