Instructions and Data Privacy

To help us better serve you, please fill out this questionnaire. The information you provide is voluntary and will be kept confidential. You don't have to provide the information, but failure to do so could affect your eligibility for additional veteran program benefits. Please fill out all required fields in each section.

Service Member Relationship

Please select the option below that best describes you:

Your Contact Information

How would you prefer to be contacted?

Military Service Dates

Current Service Member Questions

Current service members may already be eligible for Veterans Employment Services.

You may already be eligible if any of the following circumstances apply to you:

  • You are currently receiving medical treatment for a wound, illness, or injury at a military treatment facility or in a Warrior Transition Unit.
  • You are within one year of separation from active duty or two years of retiring and have participated in any portion of the Transition Assistance Program (TAP).
  • You are a member of the National Guard or Reserves and were activated during a recognized period of conflict or campaign.
Do any of the circumstances listed above apply to you?
If your answer is "No," we will ask some additional questions to determine your eligibility.
Please select all statements that apply:

Veteran Questions

Have you served on active duty for more than 180 consecutive days and were discharged with other than a dishonorable discharge?
Were you released from active duty due to a service-connected disability?
Have you been discharged or released from active duty due to a “Sole Survivorship”?
Are/were you a member of the National Guard or Reserves and were activated during a recognized period of conflict or campaign?

Spouses and Caregivers Questions

Are you a spouse or family caregiver of a wounded, ill or injured service member who is receiving care at a military treatment facility?
Are you a surviving spouse of a veteran who passed away due to a service-connected disability?
Are you a spouse of a veteran who has a total and permanent service-connected disability?
Are you a spouse of a veteran who has been listed as ‘MIA’, captured in the line of duty by a hostile force, or forcibly detained by a foreign government or power, for more than 90 days?

Qualifying Circumstances Questions

Are you a veteran with a service-connected disability receiving compensation from the VA, or have a pending claim?
Do you have a disability as defined by the Americans with Disabilities Act?
Are you a Viet Nam Era Veteran who served in the Republic of Vietnam between 11/1/1955 and 5/7/1975, OR served (regardless of location) between 8/5/1964 and 5/7/1975?
Were you discharged or released from active duty within the last three years?
Were you referred for employment services by a Department of Veteran Affairs Representative?
Are you homeless or at risk of becoming homeless?
Are you justice-involved and need assistance with finding employment?
Are you between the ages of 18-24 years old?
Do you lack a high school diploma or GED?
Have you received public assistance from any source, including government, state, or county in the last six months?
Are you low-income or below the poverty line?
Are you currently unemployed and seeking employment?
Are you the head of a single-parent household containing at least one dependent child?

Contact CareerForce

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Contact CareerForce

Contact CareerForce