|
RELEASE
OF INFORMATION
CLAIMANT:__________________________________________
CLAIM NO:____________________________
I authorize the National Personnel
Records Center, St. Louis, MO, or other my military record to release to
the Department of Labor and industries information or copies from my
military personnel and related medical records. This could copy include a
copy of my DD form 214, Report of Separation.
NAME: ________________________________________________________________________________
SERVICE NUMBER:_______________________________________________________________________
BRANCH OF SERVICE: DATES OF SERVICE:_________________________________________
SOCIAL SECURITY NUMBER:_____________________________________________________
Have you ever filed for Veterans, Disability Compensation?___________________________________
SIGNATURE:_________________________________________DATE:______________________
|
