Referral - Vetus Legal™

Your Company Name *

Salutation

First Name *

Middle Name or Initial.

Last Name *

Preferred Name or Nickname (if any)

Mailing Address Line 1 (street address or PO box) *

Mailing Address Line 2 (e.g. apartment number)

City *

State (two-letter abbreviation) *

Zip Code +4 *

Primary (Preferred) Phone Type

Primary (Preferred) Phone Area Code (without parentheses) *

Primary (Preferred) Phone Number (xxx-yyyy) *

Secondary (Alternate) Phone Type

Secondary (Alternate) Phone Area Code (without parentheses)

Secondary (Alternate) Phone Number (xxx-yyyy)

Your Email: *

VA Claim Number

Date of BVA Merits Decision (MM/DD/YYYY) (not reconsideration denial date)

Date of BVA Reconsideration Denied (MM/DD/YYYY) (if any)

Gender *

Additional Information

1-516-774-2678