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2. Would you like to schedule an appointment with the Department of Veterans Affairs? Give us some information and we will contact you to get you scheduled!

4. First Name*
5. Last Name*
7. Phone Number*
8. Email Address*
10. Reason for Appointment*

    Please provide a brief description of the reason for your meeting request.

12. Are you a Veteran or Veteran's Dependent?*
    -- Select One --Lenawee County VeteranDependent of a Lenawee County Veteran
14. Relationship to Veteran
    -- Select One --SpouseChildOther

    Dependent's Only

15. Veteran's Full Name

    Dependent's Only

17. Preferred Time of Day for Appointment

    1. Morning
    2. Afternoon
    3. First Available
    4. No Preference
18. Preferred Day of the Week for Appointment

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. First Available
    6. No Preference
20. Preferred Method of Contact*

    1. Phone
    2. Email
Leave This Blank:


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

    This field is not part of the form submission.

24. Submit

* indicates a required field