Gillespie County
BLUE WATER NAVY WORKSHEETName: __________________________Branch of Service: ___________________Ships You served on off the coast of Vietnam and dates you were onboard ship:_________________________________________________________________Provide Documentation of Ship assignment (orders, DD-214, award citation, evaluations, service record documenting duty stations: ________________________________________________________________What Agent Orange Disabilities have you been DIAGNOSED with (see attached list):_________________________________________________________________Have you been treated for the Agent Orange disability by a private physician or VA health care or both? _____________________________________________Complete the two documents and bring to your initial appointment:VA Form 21-22 Appointment of a Veterans Service OrganizationVA Form 21-0966 Intent to File ................
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