We Drive AZ - Veteran Application
Name
*
Required
First Name
Required
Last Name
Address
*
Required
Street Address
Address Line 2
Required
City
Required
State/Region/Province
Required
Postal / Zip Code
Contact Number
*
Required
Email
*
Required
Military Status
*
Required
Veteran
Active Duty
National Guardsman
Reservist
Can you provide proof of service?
*
Required
Yes
No
DD 214 or similar document.
What is your current employment status?
*
Required
Currently Employed
Actively seeking employment
Need employment support and resources
Do you require a vehicle?
*
Required
Yes
No
Select no and continue the form if you're applying for repairs. If selecting yes skip down to the next mandatory question (asterisk)
Provide a brief summary of the current maintenance/repairs needed for your vehicle:
Only fill in if you're applying for repairs.
Vehicle Identification Number:
Only fill in if you're applying for repairs.
Vehicle License Plate Number:
Only fill in if you're applying for repairs.
What transmission does your vehicle have?
Automatic
Manual
Automated Manual Transmission (AMT)
Continuously Variable Transmission (CVT)
Only fill in if you're applying for repairs.
What is your vehicles drivetrain type?
Front Wheel Drive (FWD)
Rear Wheel Drive (RWD)
Four Wheel Drive (4WD)
All Wheel Drive (AWD)
Only fill in if you're applying for repairs.
How has not having reliable transportation currently impacting your day to day activities?
*
Required
Examples: Employment, healthcare appointments, etc.
Do you need any other support services?
*
Required
Mental Health
Substance Abuse
Employment
Housing
Legal
Social Support
Education
Physical Health
VA Benefits and Claims
Spirituality
Transportation
Food
Other
None
Check any that apply
May We Drive AZ use your story for promotional purposes?
*
Required
Yes
Yes - Anonymously
No
Please provide any additional information that may assist us in processing your application:
I understand my information will not be sold to any third party. I also understand that my application does not guarantee that I'm eligible for support. I also give permission to We Drive AZ to contact me to discuss the next steps:
*
Required
I agree
I DO NOT agree
I declare that the information provided in this form is accurate and true to the best of my knowledge. I understand that We Drive AZ assists veterans who are in need, and I meet this criterion.
*
Required
E-Signature Field
Clear
Please sign your name to affirm.
Submit
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