City, ST Zip: *
Telephone #: *
Email
Campus: *
- Select - AFRH-DC AFRH-GP Either GP or DC
Birthdate *
Marital Status: *
- Select - Married Single Widowed Divorced Separated Other:
Other: *
How did you hear about AFRH?
Publication/Advertisement *
- Select - DFAS Newsletter U.S. Air Force Afterburner U.S. Army Echoes U.S. Coast Guard – The Retiree Newsletter U.S. Marines – Semper Fi U.S. Navy Shift Colors AFSA Magazine (Air Force Sergeants Assoc.) MOVA Mayor’s Office of Veterans Affairs (District of Columbia) The American Legion Magazine FRA Today Magazine (Fleet Reserve Assoc.) The Graybeards Magazine (Korean War Veterans) NCOA e-newsletter (Non-Commissioned Officers Assoc.) The VOICE of the Enlisted Magazine (TREA The Retired Enlisted Assoc.) The Submariner Magazine VFW Magazine (Veterans of Foreign Wars) The VVA Veteran Magazine (Vietnam Veterans of America) USA Today Special Veterans Affairs Edition The Beacon Military Times Email Advertisement Facebook Adverstisement Website AFRH.gov Online Search None Other Advertisement:
Military Associations/Events *
- Select - None AFSA Air Force Sergeants Assoc. (Nat’l Conv / Mtg) American Legion (Nat’l Conv / Mtg) DAV Disabled American Veterans (Nat’l Conv / Mtg) FRA Fleet Reserve Assoc. (Nat’l Conv / Mtg) VFW Veterans of Foreign Wars (Nat’l Conv / Mtg) VVA Vietnam Veterans of America (Nat’l Conv / Mtg) Attended an event or volunteered at AFRH Other
Other *
Retiree Appreciation Day Event at base *
Referrals or other sources: *
Please describe below if you learned about AFRH from someone like a friend, AFRH Resident, AFRH Staff Member, VA referral, family member or if you knew about AFRH because you lived or worked nearby, payroll deductions, visited AFRH, saw it on the news, etc. If you can provide a person’s name, they may be credited with the referral.
ELIGIBILITY INFORMATION
Active (Regular Military) *
Inactive (Guard/Reserves) *
Rank/Grade *
Enlisted/Non-Comm: *
Active-Duty
Commissioned Officer:
Active-Duty
Nat’l Guard/Reserves:
Inactive-Duty
VA Service-Connected Rating: *
% SCD
Other: *
Wars/Class: (list all) *
Examples: Vietnam/WT, Korea/ERA, Submarine Duty/HFP, Liberia/IDP, none, etc.
Note: Any officially designated war theaters will be listed on the veteran’s DD-214 but IDP/HFP hostile zones may not be included. (additional documentation may be needed for those applying under Category 3 with hostile fire pay as proof of eligibility)
Multiple awards, other: *
Insurance
All applicants must be enrolled in acceptable health insurance prior to being approved for admission. Anyone over 65 must have both Medicare A&B and Supplemental Insurance or 100% VA benefits. Those under 65 who have less than a 100% VA disability rating, must have major medical insurance covering hospitalization, medical visits and prescriptions.
other*: *
Other insurance provider (name)*: *
Health / Independence
Other limitations/support needs: *
Other: *
How soon would you be interested in moving if you are eligible?
Other: *