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Office Use Only Appointment with (Curt or Jennifer): Date: Time: Last Name: First Name: Middle Name: Address: City: State: Zip: Sex (Male/ Female): Race (White, American Indian/Alaska Native, Black/African American, Native Hawaiian/Pacific Islander, Spanish/Hispanic/Latino, Asian): Home Phone: Cell Phone: Date of Birth: Place of Birth (City, State): Email Address: Date of Death: Place of Death (City, State): Branch of Service: Social Security Number: Maiden Name: Serve Under Any other Name: Marital Status (Single/Married/Divorced/Widowed): Date of Marriage: Place of Marriage (City, State): Date of Divorce: Place of Divorce (City, State): Living with Spouse? (Yes/No): Employer: Occupation: Employer Address: City: State: Zip: Phone: Fax: Job Title: Dates of Employment: Last Name: First Name: Middle Initial: Sex (Male/ Female): Social Security Number: Maiden Name: Cell Phone: Work Phone: Previously Married (Yes/No): Also a Veteran (Yes/No): Date of Birth: Place of Birth (City, State): Email Address: Date of Death: Place of Death (City, State): Employer: Occupation: Employer Address: City: State: Zip: Phone: Fax: Job Title: Dates of Employment: Clay County Veterans Service Office 715 11th Street North, Suite 103 Moorhead, MN 56560 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] Veteran Spouse Veteran Employment Spouse Employment Important Note: After completing and printing the form, make sure you CLEAR the form by clicking the "CLEAR FORM" button at the end of the form. If you do not CLEAR the form, your information will be disclosed to those persons subsequently using the computer. ---PAGE BREAK--- Last Name: First Name: Middle Initial: Social Security Number: Date of Birth: Place of Birth (City, State): Sex (Male/Female): Relation to Veteran (Biological/Step Child/Adopted): Student? (Yes/No): Adult? (Yes/No): Disabled? (Yes/No): Name of School: Disability: Last Name: First Name: Middle Initial: Social Security Number: Date of Birth: Place of Birth (City, State): Sex (Male/Female): Relation to Veteran (Biological/Step Child/Adopted): Student? (Yes/No): Adult? (Yes/No): Disabled? (Yes/No): Name of School: Disability: Last Name: First Name: Middle Name: Street Address: City: State: Zip Code: Daytime Phone: Evening Phone: Relation to Veteran: Last Name: First Name: Middle Name: Street Address: City: State: Zip Code: Daytime Phone: Evening Phone: Relation to Veteran: Name as it appears on Medicare Card: Medicare A? (Yes /No): Effective Date: Medicare B? (Yes /No): Effective Date: Medicare D? (Yes /No): Effective Date: Type of Insurance (Medicaid/Private): Name of Company: Insurance Address: City: State: Zip Code: Policy/Identification Number: Group Number: Policy Listed Under: Coverage Ending Date: Please provide photocopies of your Military Discharge (DD214) and Insurance Card(s) Dependent Dependent Next of Kin Emergency Contact Medicare Health Insurance Important Note: After completing and printing the form, make sure you CLEAR the form by clicking the "CLEAR FORM" button. If you do not CLEAR the form, your information will be disclosed to those persons subsequently using the computer. Clear Form Print Form