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Apply for a Retreat

Below you will find the form that you need to fill out in order to be considered for the CVIP program. Please take your time and fill it out completely. If you have any questions, contact us.

General Information

Soldier Name

Spouse Name

Email

Current Address

Street Address

Street Address 2

City

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip

Time at current address:

Phone Numbers

Telephone - -

(###) - ### - ####

Telephone 2 - -

(###) - ### - ####

Military Information

Branch of Military

Years of Service

Active Duty Dates

Rank

Specialty (MOS)

Date Entered

Dishcarge Date

Are you now a member of the ARNG/ANG? Yes No

Reserve: Yes No

AD: Yes No

Education Information

Education Completed (Degree)

High School

College

Business/Trade School

Professional School

Personal History

Have you ever been convicted of a crime? Yes No

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

History of mental illness? Yes No

If yes, give details.

History of substance abuse? Yes No

If yes, give details.

Do you have a valid Driver's License? Yes No

Employment Information

Name of Employer

Employer Address

Supervisor

Employment Dates

Employer Phone

Job Title

Retreat Information

Requested Retreat Date

Alternative Retreat Date

Did you complete this form yourself? Yes No

If not, who did?

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By completing this form you signify that everything in this form is accurate to the best of your knowledge.