Section 1 of 1 in this document
Veteran's Court Application
Client Information
Client's Name
First Name
*
Last Name
*
Phone
Alternate Phone
Email
Is the client currently incarcerated at Chester County Prison?
*
Choose One
Yes
No
Date of incarceration
*
OTN(s)
Case Number(s)
Current Criminal Charges
Is the client currently on probation/parole?
*
Choose One
Yes
No
Unknown
Service History
Which branch of the Armed Forces did you serve? (select all that apply)
Army
Army National Guard
Army Reserve
Marine Corps
Marine Corps Reserve
Navy
Navy Reserve
Air Force
Air National Guard
Air Force Reserve
Coast Guard
Coast Guard Reserve
Date entered into the Armed Forces
Month
*
MM
January
February
March
April
May
June
July
August
September
October
November
December
Day
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
Date of last discharge
Month
*
MM
January
February
March
April
May
June
July
August
September
October
November
December
Day
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
How long did you serve in the Armed Forces?
*
What type of discharge did you receive?
*
Choose One
Honorable
General
Other Than Honorable
Dishonorable
Bad Conduct
Have you ever served in any capacity in combat?
*
Choose One
Yes
No
Where were you stationed during combat / theater?
*
Have you ever been stationed or deployed outside of the US?
*
Choose One
Yes
No
Where were you deployed?
Have you ever been awarded an overseas deployment badge or ribbon?
*
Choose One
Yes
No
Where were you awarded a badge or ribbon?
MOS Number
*
Have you ever received services at a VA hospital?
*
Choose One
Yes
No
At what hospital did you receive services?
Referral and Attorney Information
Referrer Name
*
Referrer Email
*
ReferingAgency (if applicable)
Relationship to client
*
Attorney Name
Attorney Email
Enter email to receive a copy of this submission
Attach DD214 and Criminal Complaint
Recaptcha Response
Be sure to verify that you are not a robot by using the Captcha tool at the below.
Having reCaptcha issues? Click here to reset the widget.
disregard this