Veteran Intake Form | Johnston County Veterans Services

Complete all required fields below. After you submit, your information is reviewed by the Veterans Services Office before it is processed. Never submit passwords through this form.

Veteran's Contact Information

Veteran's Phone Number (required)

Veteran's Email Address (required)

Veteran's Home Street Address (required)

City (home address) (required)

State (home address) (required)

Zip Code (home address) (required)

County of Home Address (required)

Country of home address

US Other

Mailing address same as home address? (required)

Yes No

Service Information

Do you have a copy of you DD-214

Yes No

Have you ever been a prisoner of war? (required)

Yes No

Military Component (required)

Branch of Service (required)

Rank (required)

Conflict

Entry Date (required)

Separation Date (required)

Character of Discharge (required)

City where entered service (required)

State (where entered service) (required)

Country (where entered service)

US Other

City where separated from service (required)

State (where separated) (required)

Country (Where separated) (required)

US Other

Dependent Information

Are you married? (required)

Yes No

Dependent Children

Do you have dependent children? (required)

Yes No

Info for the VSO

This will help the Service Officer prepare for the appointment!

Have you ever filed a claim with the VA before?

Yes No

Are you enrolled in VA Healthcare?

Yes No

Please list any VA or DoD facilities where you have received medical treatment.
(e.g., Durham VAMC, Fort Bragg WOMACK Army Medical Center)

What would you like to discuss during our appointment?
The more details you can share ahead of time, the better prepared we'll be to assist you. Please include any relevant topics, documents, concerns, or goals you'd like to cover. (required)

Supporting Document (optional)

If you have your DD-214 (Certificate of Release or Discharge from Active Duty), attaching it here helps us verify your service and speeds up processing. This is optional. Your document is stored securely and is visible only to our Veterans Services staff — it is never posted publicly. Accepted formats: PDF or image (JPG, PNG), up to 10 MB.

Attach DD-214 (optional — PDF or image, max 10 MB)

Additional Supporting Documents (optional — e.g. award letters, marriage or birth certificates; you may select more than one)