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* 1. What is your Branch of service ?

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* 2. ‎ What are your dates of service?

Date
Date

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* 3. Are you a Disable Veteran and if so, what is your disability rating?

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* 4. ‎ What is your age group?‎

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* 5. ‎ As a Women Veteran, what are you most concerned with? Check all that apply.‎

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* 6. Where would you like to see more Benefits and Healthcare focus?

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* 7. Have you enrolled with the VA health care facility nearest you? If not, why ‎?

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* 8. What healthcare issues are you most concerned about? Check all that apply.‎

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* 9. ‎ What county do you live in?‎

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* 10.  ‎ ‎Comments_______________________________________________________________________‎‎________________________________________________________________________________‎‎________________________________________________________________________________‎‎________________________________________________________________________________‎‎________________________________________________________________________________‎‎________________________________________________________________________________‎‎___________________________________________________________________‎

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