Contact Information

First Name

Last Name

Street Address

City

State

Zip Code

Define where are you currently residing

Mobile Phone Number

Home Phone Number

Email Address

Emergency Contact Name

Emergency Contact's Mobile Number

Emergency Contact's Home Number

Emergency Contact's Email Address

Name of the person who recommended you to The Reveille Foundation

Have you served in the US Military

Military History

Service Status

Service Component

Branch of Service

Service Start Date

Service End Date

Rank

Grade

AFSC/MOC/MOS Job Code

Number of Deployments (if any)

Type of Discharge

Do you have a Service-Connected Disability?

Disability Rating

Do you have a copy of your DD214?

Please Attach a Copy of Your DD214 Here

With Which Areas Do You Need Assistance?

Please select one:

Subject (Brief Description)

Please describe in detail exactly what assistance you desire from Reveille Foundation to help you achieve your goals:

Are you currently having financial hardship, such as difficulty paying for rent or utilities?

Have you ever used financial resources or funding such as WIOA, SSVF, CAP, or assistance from other organizations?

If yes, please explain:

How Do You Describe Yourself?

What is your Ethnicity? (Select all that apply)

Other Race (Please List)

Are you Hispanic, Latino, or Spanish?

Are you a US Citizen?

Date of Birth

Number of Household Members

Number of Children

What is your Employment Status?

Name of Company Where Most Recently Employed

Position

Position Start Date

Position End Date

Current Income

Source(s) of Income

What is your Highest Level of Education?

Your Current Educational Status?

Degree Status/Type

Are you receiving SSA Benefits SSI/SSDI?

Are you considered Unemployable (TDIU) by the VA?

Are you currently receiving AHCCCS, Medicaid, or Snap Assistance?

If yes, what services are you receiving?

AHCCCS#

Provider Name

Enrolled in eBenefits?

Are you Eligible for Tricare?

Are you Enrolled in Tricare?

Are you Eligible for VA Healthcare?

Are you Enrolled in VA Healthcare?

Are there any barriers that might be obstacles to your success?

Other Obstacles:

Have you ever been convicted of a misdemeanor or felony?

If Yes, please explain:

Do you currently have a problem with alcohol?

Do you currently have a problem with drugs (Prescription, or illegal)?

Do you have Transportation?

What mode of transportation do you use?

Do you have a valid driver's license?

Do you have access to a computer?

If you are seeking employment assistance, what are your employment goals?

How many miles are you willing to travel for work?

Do you require any accommodations for work?

Please explain accommodations:

Do you have a current resume for work?

Please attach your resume here.

Contact Information