Va Form 28-1900 - Disabled Veterans Application For Vocational Rehabilitation
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2OMB Approved No. 2900-0009
Respondent Burden: 15 minutes
Expiration Date: 09/30/2017
DISABLED VETERANS APPLICATION FOR VOCATIONAL REHABILITATION
(Chapter 31, Title 38, U.S.C.)
PURPOSE OF VOCATIONAL REHABILITATION: Vocational Rehabilitation provides services and assistance to certain veterans with
disabilities to get and keep a suitable job. If employment is not reasonably feasible, vocational rehabilitation may be able to provide services to
support veterans with disabilities to achieve maximum independence in their daily living activities.
IMPORTANT: To see if you should fill out this form, please read the information on back.
If different, from Item 2)
1. FIRST, MIDDLE, LAST NAME OF VETERAN
2. SOCIAL SECURITY NO.
3. VA FILE NO. (
4. DATE OF BIRTH
(Month, Day, Year)
(No. and street or rural route, City, State and
5A. MAILING ADDRESS
6. DAYTIME TELEPHONE NO.
8. VA OFFICE WHERE RECORDS ARE
ZIP Code)
(Include Area Code)
LOCATED
7. EVENING TELEPHONE NO.
9. NUMBER OF YEARS OF EDUCATION
(Include Area Code)
(If, available)
5B. E-MAIL ADDRESS OF VETERAN
10. IF YOU ARE MOVING WITHIN THE NEXT 30 DAYS,
11. LIST ANY PREVIOUS VOCATIONAL REHABILITATION
DO NOT WRITE IN THIS SPACE
PROGRAMS YOU HAVE BEEN IN AND GIVE THE
GIVE US YOUR NEW ADDRESS
(VA DATE STAMP)
Include both VA and non-VA programs)
DATES (
PROGRAM
DATE
12. SERVICE INFORMATION (Enter the following information for each period of active duty. Show ALL active duty)
DATE ENTERED
DATE LEFT
TYPE OF SEPARATION
SERVICE NUMBER
(Prefix and suffix)
BRANCH OF SERVICE
ACTIVE DUTY
ACTIVE DUTY
OR DISCHARGE
(A)
(B)
(C)
(D)
(E)
13. IF YOU ARE NOW WORKING (Enter the following information for your current job)
A. NAME AND ADDRESS OF EMPLOYER
B. DUTIES OF YOUR JOB
C. MONTHLY SALARY OR WAGES
14. IF YOU ARE NOW HOSPITALIZED, WHAT IS THE NAME AND ADDRESS OF YOUR HOSPITAL?
15B. WHAT IS THE NATURE OF YOUR DISABILITY (DISABILITIES)?
15A. WHAT IS YOUR DISABILITY RATING?
(Check appropriate box(es))
16. DID YOU SERVE IN:
17. DISABLED TRANSITION
GULF WAR
ASSISTANCE PROGRAM
WORLD WAR II
POST KOREAN CONFLICT
(DTAP)?
OPERATION ENDURING FREEDOM
POST WORLD WAR II ERA
VIETNAM
KOREAN CONFLICT
OPERATION IRAQI FREEDOM
YES
NO
POST VIETNAM
I HEREBY CERTIFY THAT the information I have entered on this form is true and complete to the best of my knowledge and belief.
I realize that making willful false statements concerning a material fact in a claim of vocational rehabilitation benefits is a punishable
offense that may result in fine or imprisonment or both.
(Do not print) (Sign in ink)
18B. DATE SIGNED
18A. SIGNATURE OF APPLICANT
VA FORM
28-1900
SUPERSEDES VA FORM 28-1900, JUN 2011,
PAGE 1
SEP 2014
WHICH WILL NOT BE USED.
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