Services are subject to available funds at the time of the request.

Services are available to Active Duty Service Members who are wounded, injured or critically ill. 

Services are available to Disabled Veterans with an established disability rating of 50% or higher within the Veterans Administration.

Services are available to Service Members and Disabled Veterans attending an in-patient PTSD Treatment Program or a PTSD medical procedure.

Must have at least 6 months of active duty.

Active Duty Service Members and Disabled Veterans

Today's Date
Full Name (First Middle Last)
Street Address (Include Apt #)
City
State
County
Zip Code
Phone Number
Date of Birth
Last 4 of SS #
Number of Children Under 18 Years Old Living at Home
Your Email Address
Confirm Your Email Address
Branch of Military
Amount of Time Served (Must be at least 6 months of active-duty Example: 6 Years or 36 Months)
Disability Rating % (Must be an Established rating of 50% or higher, your disability rating CANNOT be a proposed or pending rating) This is your Veterans Administration rating not SSA or SSDI
Please share what has happened that caused your current financial hardship. (Please be as specific as possible. Your response helps us understand your situation so we can best determine how to assist you. All information shared is kept confidential.)
Please break out each need and it's amount (example: rent $1,000, utility $250, groceries $400 ect... NOT JUST A TOTAL)
Would you be interested in taking an online Cisco Certified Network Associate Course for no cost to you?
Would you be interested in taking an online CompTIA Security+ Cyber Security Course for no cost to you?
The applicant agrees that the name appearing in the signature block below is the true and legal name of the applicant and serves as an electronic "signature" to this application form. (This must be the Service Member or Veteran's signature)
*VERY IMPORTANT* Any altered or falsified documentation is considered a felony.
Please Understand the Following
Submit