First Name:

Last Name:

Screen Name:

Email:

Password:

Phone Number:

Would You Like To Receive Taxts Info: Yes
No

Wouldd You Like To Recieve EMails: Yes
No

City You Live In:

State You Live In:

Date Of Birth:

Are You a BVA Member: Yes
No

I was in the:* Army
Air Force
Coast Guard
Marine Corps
Navy
Space Force
None

What VA Center do you go to:

Who is your Vist Coordinator

Have you ever been to a BRC: Yes
No

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