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First & Last Name
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Email
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Phone
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Birthday
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Month
Day
Year
Address (Include City, State & Zip code)
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Date Diagnosed with PTSD:
Last 2 Medical Employers (include address & phone #):
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Career Documentation (first & last pay statement, excluding info other then name, title, dates) offer letter, including company letter head, etc
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Medical License or Certificate/ LEO/ EMS/ EMT/ FF ID Number:
Do you have a preferred breed?
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PTSD diagnosis medical document (if your unable to upload please let us know)
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