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Do you plan to live in San Diego, Orange, Riverside, or Imperial County when you transition from the service?

Would you like to be able to live in San Diego, Orange, Riverside, or Imperial County when you transition from the service?

Number of months until terminal leave begins?

First Name:

Last Name:

What is your email address (please do not use your military email)

(non-military Email)

What is your phone number?

What is an alternate phone number?

Where did you hear about zero8hundred?

Please choose the role that best describes you.

Other Role:

With which branch of service are you currently associated?

Other Branch of Service:

Where do you plan to reside after separation?

Where do you plan to work or go to school after separation?

What is your rank?

Are you prior enlisted?

What is your current or anticipated discharge status?

What is the month and year of your separation/retirement date from active duty?

Are you separating or retiring?

What is your date of birth?

(DD/MM/YYYY)

How do you identify? (Gender)

Other Gender:

What is your marital status?

How many children under the age of 18 are in your household?

How many children 18 years of age or older are in your household?

How do you identify? (Ethnicity)

How many PCS moves have you made?

What is the highest level of education you have completed?

What is your primary need?

Other Primary Need

What is your secondary need?

Other Secondary Need

What is your preferred time to be contacted by a Peer Navigator?

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