NOTICE AND WARNING This computer system is the property of the Commonwealth of Virginia and is intended for authorized users only. By accessing and using this system you are consenting to system monitoring for law enforcement and other purposes. Unauthorized use of this system may subject you to State or Federal criminal prosecution and penalties.

==================================================================================================================================== First Name* Last Name* E-Mail Address* Customer Number* Phone Number ==================================================================================================================================== Please identify the type of proof document you are supplying: DD 214 DD 256 NGB 22 WD AGO Other veteran service proof document(s) indicating branch of service, discharge date and discharge The system ONLY permits the following file extensions (TIF,JPG,PDF and PNG) Upload your Documents* Drop files here, or browse to attach files Cancel All Confirmation Required Are you sure you want to remove the selected file? ConfirmCancel ==================================================================================================================================== CERTIFICATION I certify and affirm that all the information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement on this form is a criminal violation. Furthermore, I understand that DMV will share the information I have provided on this form with the Virginia Department of Veterans Services (DVS) and I consent to this sharing of my information. I understand that any address change information I provide to DMV at any time in the future will also be shared with DVS and I consent to such future sharing of address information. ====================================================================================================================================