FIU VetSuccess
FIU VetSuccess
Name
Name
*
First
Last
Social Security
*
Panther ID
*
Date of Birth
Date of Birth
*
/
MM
/
DD
YYYY
Current Military Status
*
Current Military Status
Active duty
Reserve/ NATL guard
Veteran
Dependent using TOE
Phone
Phone
*
-
###
-
###
####
VA Benefit Eligibility
*
VA Benefit Eligibility
Chapter 30
Chapter 31
Chapter 33
Chapter 33 TOE
1606/1607
Other
Other
Currently using VA Benefit
*
Currently using VA Benefit
Chapter 30
Chapter 31
Chapter 33
Chapter 33 TOE
1606/1607
Other
Other
Disabled Veteran
*
Disabled Veteran
Yes
No
If yes, what is service-connected disability rating?
*
If yes, what is service-connected disability rating?
Yes
No
Registered with VHA?
*
Registered with VHA?
Yes
No
Current college/school
*
Anticipated graduation date
Anticipated graduation date
*
/
MM
/
DD
YYYY
Major/degree
*
Outcome desired
*
Branch of Service
*
Date entered active duty
Date entered active duty
*
/
MM
/
DD
YYYY
Date left active duty
Date left active duty
*
/
MM
/
DD
YYYY
Type of separation or discharge
Reason for visit and actions taken:
*
How did you hear about VetSuccess?
*
How did you hear about VetSuccess?
VA Rep
Family member
School Vet Service Rep
Friend
Student
Other service rep
Other
Other
Follow up required?
*
Follow up required?
Yes
No
VSOC Counselor Signature
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Date completed & signed
Date completed & signed
*
/
MM
/
DD
YYYY
If follow up necessary indicate time and date of follow up