Last Name
First Name
Middle Initial
Street Address
City
State
Zipcode
Email Address
User Name on Forum
Phone Number
Branch of Service
First Ship
Year of WestPac Cruise
Second Ship
Year of WestPac Cruise
Phone number
Rate/Rank
Who is your VSO?
What is the date of your claim? (est. month/year)
What is the nature of your claim? (e.g., diabetes, soft tissue sarcoma, etc)
Did you also have boot-on-the-ground?
Were you ever on the rivers inland of the coast line?
Were you ever in a Harbor in Vietnam?
Do you believe you qualify for financial hardship?
Do you believe you qualify for physical hardship?
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