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Gratiot County Veterans Affairs - Request for Contact

2. Name*

3. Email Address

5. Address

7. City

8. State

9. Zip Code

11. Phone Number*

13. Are you a Veteran?*

    1. Yes
    2. No

15. Branch of Service

17. Era

    (Peacetime, WWII, Korea, Vietnam, Gulf War, etc.)

19. Reason for Contact

Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field