Wisconsin Women Veterans Registry

Women Veterans Registry

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

County

Phone

Cell: (if Different)

Service Branch (check all that apply)

Army

Navy

Air Force

Marines

Coast Guard

Army Reserve

Navy Reserve

Marine Reserve

Air Force Reserve

Coast Guard Reserve

Air National Guard

Army National Guard

Space Force

Are you currently serving the military?

Yes No

Dates of Service - Entry:

Dates of Service - Discharge:

Are you retired from the military?

Yes No

Are you a member of a tribe?
Yes No

Are you a Veteran Owned Business owner?
Yes No

Are you married?
Yes No

Do you have dependent children under the age of 18?
Yes No

What are you interested in being informed about? Select as many as apply from the list below:

Women Veteran Information

Veteran Benefits

VA Healthcare

Mental Health Care

Education Benefits

Veteran Small Business

Employment/Employer Opportunities

Veteran Discounts

Preferred Method of Contact

WDVA is committed to respecting your privacy and using your information carefully and sensibly. Although we employ security measures that we believe are reasonably appropriate to protect your personal information, we do not guarantee that our security precautions will protect against the loss or misuse of any information you provide to us. Similarly, we cannot guarantee the privacy of personal information you transmit over the Internet or that may be collected in transit by others, including contractors that provide services to us. You agree that in no event shall WDVA be liable for any direct, indirect, or special or incidental damage resulting from, arising out of or in connection with the use of your information.