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Submitted URL: https://bvqevp.ff85.fdske.com/e/c/01j8gqcd04eds5rsj4qqe9tmr6/01j8gqcd04eds5rsj4qy5j9xm6
Effective URL: https://docs.google.com/forms/d/e/1FAIpQLSeBLwFQfofbcdrEIUs_x7q4rFazkpY96IK0q1K9xAMMdLHwiQ/viewform
Submission: On September 24 via manual from US — Scanned from DE
Effective URL: https://docs.google.com/forms/d/e/1FAIpQLSeBLwFQfofbcdrEIUs_x7q4rFazkpY96IK0q1K9xAMMdLHwiQ/viewform
Submission: On September 24 via manual from US — Scanned from DE
Form analysis
1 forms found in the DOMPOST https://docs.google.com/forms/d/e/1FAIpQLSeBLwFQfofbcdrEIUs_x7q4rFazkpY96IK0q1K9xAMMdLHwiQ/formResponse
<form action="https://docs.google.com/forms/d/e/1FAIpQLSeBLwFQfofbcdrEIUs_x7q4rFazkpY96IK0q1K9xAMMdLHwiQ/formResponse" target="_self" method="POST" id="mG61Hd" jsmodel="TOfxwf Q91hve CEkLOc" data-shuffle-seed="390594239862286705"
data-clean-viewform-url="https://docs.google.com/forms/d/e/1FAIpQLSeBLwFQfofbcdrEIUs_x7q4rFazkpY96IK0q1K9xAMMdLHwiQ/viewform" data-response="%.@.]" data-dlp-data="%.@.null,false]" data-first-entry="0" data-last-entry="10" data-is-first-page="true">
<div jscontroller="yUS4Lc" jsaction="rcuQ6b:rcuQ6b;UxRBlf:rcuQ6b;">
<div jsname="o6bZLc"><input type="hidden" name="entry.1643562184" value=""><input type="hidden" name="entry.79478546" value=""><input type="hidden" name="entry.82828714" value=""><input type="hidden" name="entry.484690814" value=""><input
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name="entry.606787305" value=""><input type="hidden" name="entry.734492606" value=""></div>
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<div class="Dq4amc">
<div class="m7w29c O8VmIc tIvQIf"><noscript>
<div class="HB1eCd-X3SwIb-haAclf">
<div class="HB1eCd-X3SwIb-i8xkGf">
<div class="tk3N6e-cXJiPb tk3N6e-cXJiPb-TSZdd tk3N6e-cXJiPb-GMvhG">Die Datei kann in Ihrem Browser nicht geöffnet werden, weil JavaScript nicht aktiviert ist. Aktivieren Sie JavaScript und laden Sie die Seite noch einmal.</div>
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<div class="ahS2Le">
<div class="F9yp7e ikZYwf LgNcQe" dir="auto" role="heading" aria-level="1">VNCC VA Claims Call Request</div>
</div>
<div class="cBGGJ OIC90c" dir="auto">
<p>By providing your contact information, you agree to receive text/email messages from Veterans Network Champions Club (VNCC). Message and data rates may apply. Message frequency varies.</p>
</div>
<div jsname="F0H8Yc" class="liS6Hc"></div>
</div>
<div class="zAVwcb"></div>
<div class="DqBBlb">
<div class="Oh1Vtf">
<div class="kesdnc" id="SMMuxb">
<a jscontroller="A2m8uc" jsaction="rcuQ6b:npT2md; click:mAWTmb;" href="https://accounts.google.com/Login?continue=https%3A%2F%2Fdocs.google.com%2Fforms%2Fd%2Fe%2F1FAIpQLSeBLwFQfofbcdrEIUs_x7q4rFazkpY96IK0q1K9xAMMdLHwiQ%2Fviewform%3Ffbzx%3D390594239862286705" aria-describedby="SMMuxb">In Google anmelden</a>,
um den Fortschritt zu speichern. <a class="TYUeKb" jscontroller="rmdjlf" jsaction="rcuQ6b:npT2md; click:xdDXgc;" role="button" tabindex="0">Weitere Informationen</a></div>
</div>
<div class="zAVwcb"></div>
<div class="md0UAd" aria-hidden="true" dir="auto">* Gibt eine erforderliche Frage an</div>
</div>
</div>
</div>
<div class="o3Dpx" role="list">
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[818003145,"First Name",null,0,[[1643562184,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"First Name"]],"i1","i2","i3",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i1" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i4"><span class="M7eMe">First Name</span><span class="vnumgf" id="i4" aria-label="Pflichtfrage"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i2"></div>
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</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
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<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="text" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i1" aria-describedby="i2 i3" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Meine Antwort</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i3" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[265176923,"Last Name",null,0,[[79478546,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"Last Name"]],"i5","i6","i7",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i5" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i8"><span class="M7eMe">Last Name</span><span class="vnumgf" id="i8" aria-label="Pflichtfrage"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i6"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="rFrNMe k3kHxc RdH0ib yqQS1 zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="aCsJod oJeWuf">
<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="text" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i5" aria-describedby="i6 i7" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Meine Antwort</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i7" role="alert"></div>
</div>
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<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[451465459,"Phone",null,0,[[82828714,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"Phone"]],"i9","i10","i11",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i9" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i12"><span class="M7eMe">Phone</span><span class="vnumgf" id="i12" aria-label="Pflichtfrage"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i10"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="rFrNMe k3kHxc RdH0ib yqQS1 zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
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<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="text" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i9" aria-describedby="i10 i11" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Meine Antwort</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i11" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[2025084008,"Email",null,0,[[484690814,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"Email"]],"i13","i14","i15",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i13" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i16"><span class="M7eMe">Email</span><span class="vnumgf" id="i16" aria-label="Pflichtfrage"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i14"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="rFrNMe k3kHxc RdH0ib yqQS1 zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="aCsJod oJeWuf">
<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="text" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i13" aria-describedby="i14 i15" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Meine Antwort</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i15" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[1264229095,"What state do live in? (NJ, VA, NY, CA, UT, Etc.)",null,0,[[1233974048,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"What state do live in? (NJ, VA, NY, CA, UT, Etc.)"]],"i17","i18","i19",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i17" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i20"><span class="M7eMe">What state do live in? (NJ, VA, NY, CA, UT, Etc.)</span><span class="vnumgf" id="i20" aria-label="Pflichtfrage">
*</span></div>
<div class="gubaDc OIC90c RjsPE" id="i18"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="rFrNMe k3kHxc RdH0ib yqQS1 zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="aCsJod oJeWuf">
<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="text" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i17" aria-describedby="i18 i19" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Meine Antwort</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i19" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[242544666,"Where did you learn about us? (Tik Tok, Facebook, IG, Friend, Etc)",null,0,[[446328900,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"Where did you learn about us? \u003ci\u003e(Tik Tok, Facebook, IG, Friend, Etc)\u003c/i\u003e\u003cbr\u003e"]],"i21","i22","i23",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i21" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i24"><span class="M7eMe">Where did you learn about us? <i>(Tik Tok, Facebook, IG, Friend, Etc)</i><br></span><span class="vnumgf"
id="i24" aria-label="Pflichtfrage"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i22"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="rFrNMe k3kHxc RdH0ib yqQS1 zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="aCsJod oJeWuf">
<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="text" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i21" aria-describedby="i22 i23" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Meine Antwort</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i23" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[1015624810,"What do you need help with? (Ex. Connecting back condition, previous denials, secondaries, increase my rating, etc.)",null,1,[[1508490758,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"What do you need help with? (Ex. Connecting back condition, previous denials, secondaries, increase my rating, etc.)\u003cbr\u003e"]],"i25","i26","i27",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i25" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i28"><span class="M7eMe">What do you need help with? (Ex. Connecting back condition, previous denials, secondaries, increase my rating,
etc.)<br></span><span class="vnumgf" id="i28" aria-label="Pflichtfrage"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i26"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="edhGSc zKHdkd kRy7qc RdH0ib yqQS1" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="RpC4Ne oJeWuf">
<div class="F1pOBe snByac" aria-hidden="true" jsname="LwH6nd">Meine Antwort</div>
<div class="Pc9Gce Wic03c"><textarea class="KHxj8b tL9Q4c" jsname="YPqjbf" data-rows="1" tabindex="0" aria-label="Meine Antwort" jscontroller="gZjhIf" jsaction="input:Lg5SV;ti6hGc:XMgOHc;rcuQ6b:WYd;" required="" dir="auto"
data-initial-dir="auto" data-initial-value="" aria-labelledby="i25" aria-describedby="i26 i27" style="height: 24px;" aria-disabled="false"></textarea></div>
<div class="z0oSpf mIZh1c"></div>
<div jsname="XmnwAc" class="Bfurwb cXrdqd"></div>
</div>
<div class="jE8NUc">
<div jsname="ty6ygf" class="YElZX Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i27" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[792068150,"Military affiliation",null,3,[[393002117,[["Active duty/transitioning",null,null,null,false],["Veteran less than 1 year",null,null,null,false],["Veteran more than 1 year",null,null,null,false],["Spouse/Relative",null,null,null,false]],true,null,null,null,null,null,false,null,[]]],null,null,null,null,null,null,[null,"Military affiliation"]],"i29","i30","i31",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i29" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i32"><span class="M7eMe">Military affiliation</span><span class="vnumgf" id="i32" aria-label="Pflichtfrage"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i30"></div>
</div>
</div>
<div jscontroller="liFoG" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;JIbuQc:d3sQLd;" class="vQES8d">
<div role="listbox" aria-expanded="false" class="jgvuAb ybOdnf cGN2le t9kgXb llrsB" jscontroller="YwHGTd"
jsaction="click:cOuCgd(LgbsSe); keydown:I481le; keypress:Kr2w4b; mousedown:UX7yZ(LgbsSe),npT2md(preventDefault=true); mouseup:lbsD7e(LgbsSe); mouseleave:JywGue; touchstart:p6p2H(LgbsSe); touchmove:FwuNnf; touchend:yfqBxc(LgbsSe|preventDefault=true); touchcancel:JMtRjd(LgbsSe); focus:AHmuwe; blur:O22p3e;b5SvAb:TvD9Pc;"
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<div jsname="LgbsSe" role="presentation">
<div class="ry3kXd" jsname="d9BH4c" role="presentation">
<div class="MocG8c HZ3kWc mhLiyf LMgvRb KKjvXb DEh1R" jsname="wQNmvb" jsaction="" data-value="" aria-selected="true" role="option" tabindex="0">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Auswählen</span>
</div>
<div class="mbHMhf" role="presentation"></div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="Active duty/transitioning" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Active duty/transitioning</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="Veteran less than 1 year" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Veteran less than 1 year</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="Veteran more than 1 year" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Veteran more than 1 year</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="Spouse/Relative" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Spouse/Relative</span>
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</div>
<div class="e2CuFe eU809d" role="presentation"></div>
</div>
<div class="OA0qNb ncFHed QXL7Te" jsaction="click:dPTK6c(wQNmvb); mousedown:uYU8jb(wQNmvb); mouseup:LVEdXd(wQNmvb); mouseover:nfXz1e(wQNmvb); touchstart:Rh2fre(wQNmvb); touchmove:hvFWtf(wQNmvb); touchend:MkF9r(wQNmvb)"
role="presentation" jsname="V68bde" style="display:none;" soy-skip="" ssk="6:Rxil4c"></div>
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</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i31" role="alert"></div>
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</div>
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<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[50102209,"Your current VA disability rating?",null,3,[[606787305,[["0",null,null,null,false],["10",null,null,null,false],["20",null,null,null,false],["30",null,null,null,false],["40",null,null,null,false],["50",null,null,null,false],["60",null,null,null,false],["70",null,null,null,false],["80",null,null,null,false],["90",null,null,null,false],["100",null,null,null,false]],true,null,null,null,null,null,false,null,[]]],null,null,null,null,null,null,[null,"Your current VA disability rating?"]],"i33","i34","i35",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i33" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i36"><span class="M7eMe">Your current VA disability rating?</span><span class="vnumgf" id="i36" aria-label="Pflichtfrage"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i34"></div>
</div>
</div>
<div jscontroller="liFoG" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;JIbuQc:d3sQLd;" class="vQES8d">
<div role="listbox" aria-expanded="false" class="jgvuAb ybOdnf cGN2le t9kgXb llrsB" jscontroller="YwHGTd"
jsaction="click:cOuCgd(LgbsSe); keydown:I481le; keypress:Kr2w4b; mousedown:UX7yZ(LgbsSe),npT2md(preventDefault=true); mouseup:lbsD7e(LgbsSe); mouseleave:JywGue; touchstart:p6p2H(LgbsSe); touchmove:FwuNnf; touchend:yfqBxc(LgbsSe|preventDefault=true); touchcancel:JMtRjd(LgbsSe); focus:AHmuwe; blur:O22p3e;b5SvAb:TvD9Pc;"
jsshadow="" jsname="W85ice" aria-describedby="i34 i35" aria-labelledby="i33" aria-required="true">
<div jsname="LgbsSe" role="presentation">
<div class="ry3kXd" jsname="d9BH4c" role="presentation">
<div class="MocG8c HZ3kWc mhLiyf LMgvRb KKjvXb DEh1R" jsname="wQNmvb" jsaction="" data-value="" aria-selected="true" role="option" tabindex="0">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Auswählen</span>
</div>
<div class="mbHMhf" role="presentation"></div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="0" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">0</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="10" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">10</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="20" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">20</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="30" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">30</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="40" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">40</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="50" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">50</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="60" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">60</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="70" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">70</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="80" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">80</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="90" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">90</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="100" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">100</span>
</div>
</div>
<div class="e2CuFe eU809d" role="presentation"></div>
</div>
<div class="OA0qNb ncFHed QXL7Te" jsaction="click:dPTK6c(wQNmvb); mousedown:uYU8jb(wQNmvb); mouseup:LVEdXd(wQNmvb); mouseover:nfXz1e(wQNmvb); touchstart:Rh2fre(wQNmvb); touchmove:hvFWtf(wQNmvb); touchend:MkF9r(wQNmvb)"
role="presentation" jsname="V68bde" style="display:none;" soy-skip="" ssk="6:Rxil4c"></div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i35" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[1158933533,"Referred by",null,3,[[734492606,[["DP",null,null,null,false],["Amy Lacy",null,null,null,false],["Brian Lofton",null,null,null,false],["David Sinsel",null,null,null,false],["Maria Anderson",null,null,null,false],["Nayeli Yurcisin",null,null,null,false],["Reggie Moore",null,null,null,false],["Vernon Cooper",null,null,null,false]],true,null,null,null,null,null,false,null,[]]],null,null,null,null,null,null,[null,"Referred by"]],"i37","i38","i39",false]">
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<div class="z12JJ">
<div class="M4DNQ">
<div id="i37" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i40"><span class="M7eMe">Referred by</span><span class="vnumgf" id="i40" aria-label="Pflichtfrage"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i38"></div>
</div>
</div>
<div jscontroller="liFoG" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;JIbuQc:d3sQLd;" class="vQES8d">
<div role="listbox" aria-expanded="false" class="jgvuAb ybOdnf cGN2le t9kgXb llrsB" jscontroller="YwHGTd"
jsaction="click:cOuCgd(LgbsSe); keydown:I481le; keypress:Kr2w4b; mousedown:UX7yZ(LgbsSe),npT2md(preventDefault=true); mouseup:lbsD7e(LgbsSe); mouseleave:JywGue; touchstart:p6p2H(LgbsSe); touchmove:FwuNnf; touchend:yfqBxc(LgbsSe|preventDefault=true); touchcancel:JMtRjd(LgbsSe); focus:AHmuwe; blur:O22p3e;b5SvAb:TvD9Pc;"
jsshadow="" jsname="W85ice" aria-describedby="i38 i39" aria-labelledby="i37" aria-required="true">
<div jsname="LgbsSe" role="presentation">
<div class="ry3kXd" jsname="d9BH4c" role="presentation">
<div class="MocG8c HZ3kWc mhLiyf LMgvRb KKjvXb DEh1R" jsname="wQNmvb" jsaction="" data-value="" aria-selected="true" role="option" tabindex="0">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Auswählen</span>
</div>
<div class="mbHMhf" role="presentation"></div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="DP" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">DP</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="Amy Lacy" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Amy Lacy</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="Brian Lofton" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Brian Lofton</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="David Sinsel" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">David Sinsel</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="Maria Anderson" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Maria Anderson</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="Nayeli Yurcisin" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Nayeli Yurcisin</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="Reggie Moore" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Reggie Moore</span>
</div>
<div class="MocG8c HZ3kWc mhLiyf OIC90c LMgvRb" jsname="wQNmvb" jsaction="" data-value="Vernon Cooper" aria-selected="false" role="option" tabindex="-1">
<div class="kRoyt MbhUzd" jsname="ksKsZd"></div><span jsslot="" class="vRMGwf oJeWuf">Vernon Cooper</span>
</div>
</div>
<div class="e2CuFe eU809d" role="presentation"></div>
</div>
<div class="OA0qNb ncFHed QXL7Te" jsaction="click:dPTK6c(wQNmvb); mousedown:uYU8jb(wQNmvb); mouseup:LVEdXd(wQNmvb); mouseover:nfXz1e(wQNmvb); touchstart:Rh2fre(wQNmvb); touchmove:hvFWtf(wQNmvb); touchend:MkF9r(wQNmvb)"
role="presentation" jsname="V68bde" style="display:none;" soy-skip="" ssk="6:Rxil4c"></div>
</div>
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<div jsname="Rfh2Tc" class="SL4Sz" id="i39" role="alert"></div>
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data-should-execute-invisible-captcha-challenge="false" data-is-receipt-checked="false">
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jsshadow="" jsname="M2UYVd" aria-label="Submit" tabindex="0">
<div class="Fvio9d MbhUzd" jsname="ksKsZd"></div>
<div class="e19J0b CeoRYc"></div><span jsslot="" class="l4V7wb Fxmcue"><span class="NPEfkd RveJvd snByac">Senden</span></span>
</div>
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jsaction="click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;"
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<div class="Fvio9d MbhUzd" jsname="ksKsZd"></div>
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Die Datei kann in Ihrem Browser nicht geöffnet werden, weil JavaScript nicht aktiviert ist. Aktivieren Sie JavaScript und laden Sie die Seite noch einmal. VNCC VA Claims Call Request By providing your contact information, you agree to receive text/email messages from Veterans Network Champions Club (VNCC). Message and data rates may apply. Message frequency varies. In Google anmelden, um den Fortschritt zu speichern. Weitere Informationen * Gibt eine erforderliche Frage an First Name * Meine Antwort Last Name * Meine Antwort Phone * Meine Antwort Email * Meine Antwort What state do live in? (NJ, VA, NY, CA, UT, Etc.) * Meine Antwort Where did you learn about us? (Tik Tok, Facebook, IG, Friend, Etc) * Meine Antwort What do you need help with? (Ex. Connecting back condition, previous denials, secondaries, increase my rating, etc.) * Meine Antwort Military affiliation * Auswählen Active duty/transitioning Veteran less than 1 year Veteran more than 1 year Spouse/Relative Your current VA disability rating? * Auswählen 0 10 20 30 40 50 60 70 80 90 100 Referred by * Auswählen DP Amy Lacy Brian Lofton David Sinsel Maria Anderson Nayeli Yurcisin Reggie Moore Vernon Cooper Senden Seite 1 von 1 Alle Eingaben löschen Geben Sie niemals Passwörter über Google Formulare weiter. Dieses Formular wurde bei Veterans Network erstellt. Missbrauch melden Formulare