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Ead information on reverse before completing this form. If additional space is required, attach a separate sheet. 2. DATE OF BIRTH 1. FIRST-MIDDLE-LAST NAME OF VETERAN 3. VETERAN' S DAYTIME TELEPHONE NO. ( 4. ADDRESS OF VETERAN (No., street or rural route, city or P.O., State and Zip Code) ) 5. MAIL CERTIFICATE OF ELIGIBILITY TO: (Complete ONLY if the Certificate is to be mailed to an address different from the one listed in Item 4) 6. MILITARY SERVICE DATA (ATTACH PROOF OF SERVICE - SEE P.

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