2. Applicant must complete section I, forward to regional office of veteran's administration where disability claim is now on file.
   I hereby authorize you to furnish the Yates County Personnel Office with my medical and disability record. You are released from all liability in complying with this request. It is understood that all information furnished will be treated as confidential.
4. Veterans Signature
   By typing your name into this field you authorize Yates County to consider this an electronic signature.
6. Address
8. City
9. State
10. Zip Code
12. Service Serial Number
13. Examination or Eligible List for Which Preference is Claimed
    Exam Number and Title
Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field