Vsd 001 Form PDF Details

On July 1, 2016, the Department of Veterans Affairs (VA) will implement a new Patient Registration System called VSD 001 Form. This system is part of the VA's effort to modernize its health care operations and deliver better services to veterans. The new system will allow veterans to more easily register for VA health care and access their medical records. It will also make it easier for VA staff to track patient information and provide timely care. The VSD 001 Form is a required registration form that all veterans must complete in order to receive VA health care. Completed forms can be submitted online or in person at a local VA clinic or office.

Here, you will see quite a few information about vsd 001 form PDF. Before you fill in the form, it can be worth checking more details on it.

QuestionAnswer
Form NameVsd 001 Form
Form Length1 pages
Fillable?Yes
Fillable fields7
Avg. time to fill out1 min 39 sec
Other namesva form vsd 001 form, form vsd001, vsd 001 form, vsd001 dmv form

Form Preview Example

State of California

Veteran Status and Service-Connected Disability Verification

SECTION 1 - TO BE COMPLETED BY THE APPLICANT REQUESTING VETERAN STATUS AND/OR SERVICE CONNECTED DISABLITY VERIFICATION PRINT USING BLUE OR BLACK INK

FIRST NAME

MIDDLE NAME

LAST NAME

SUFFIX

DRIVER LICENSE OR IDENTIFICATION NUMBER

STATE OF ISSUANCE

DATE OF BIRTH (MM/DD/YYYY)

EMAIL ADDRESS

DAYTIME TELEPHONE NUMBER

MAILING ADDRESS

CITY

STATE

ZIP CODE

RESIDENCE ADDRESS IF DIFFERENT FROM MAILING ADDRESS ABOVE

CITY

STATE

ZIP CODE

SECTION 2 - APPLICANT CERTIFICATION

I certify (or declare) under penalty of perjury under the laws of the State of California, that I have served in the United States uniformed services and received an other than dishonorable discharge, or served in a Guard or Reserve component and was mobilized for federal active duty. The information I provided is true and correct. I authorize County Veterans Service Office (CVSO) employees, officers, and designees to verify the documents presented.

APPLICANT SIGNATURE

_

DATE

SECTION 3 - TO BE COMPLETED BY AUTHORIZED COUNTY VETERANS SERVICE OFFICE EMPLOYEE, OFFICER, OR DESIGNEE

COUNTY VETERANS SERVICE OFFICE ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

COUNTY

EMAIL ADDRESS

As a representative of the County Veterans Service Office of the above named county, and designee of the California Department of Veterans Affairs, I certify under penalty of perjury under the laws of the State of California, that I have reviewed the documentation required and that the above named individual meets the qualifications noted above.

COUNTY VETERANS SERVICE OFFICE REPRESENTATIVE'S SIGNATURE

DATE

COUNTY VETERANS SERVICE OFFICE REPRESENTATIVE'S PRINTED NAME

TITLE

This form must be submitted in person to the Department of Motor Vehicles along with an application for a driver license or identification card in compliance with California Vehicle Code § 12811 (c)(5) and all requirements must be met prior to the issuance of a driver license or identification card with a veteran designation on the face of the card. In addition to any other fee, a $5 fee must be paid for the veteran designation.

SECTION 4 -

DISABLED VETERAN CERTIFICATION FOR DISABLED VETERAN LICENSE PLATES

 

 

TO BE COMPLETED BY AUTHORIZED COUNTY VETERANS SERVICE OFFICE EMPLOYEE, OFFICER, OR

DESIGNEE

The above named applicant is a disabled veteran who, as a result of injury or disease suffered while on active service with the armed forces of the United States, suffers from one or more of the following disabilities:

Has a disability which has been rated at 100% by the United States Department of Veterans Affairs, due to a diagnosed disease or disorder which substantially impairs or interferes with mobility.

Is so severely disabled as to be unable to move without the aid of an assistant device.

Has lost, or has lost use of, one or more limbs.

Has suffered permanent blindness, as defined in Section 19153 of the Welfare and Institutions Code.

SECTION 5 - TO BE COMPLETED BY AUTHORIZED COUNTY VETERANS SERVICE OFFICE EMPLOYEE, OFFICER, OR DESIGNEE

COUNTY VETERANS SERVICE OFFICE ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

COUNTY

EMAIL ADDRESS

As a representative of the County Veterans Service Office of the above named county, and designee of the California Department of Veterans Affairs, I certify under penalty of perjury under the laws of the State of California, that I have reviewed the documents

for the above named applicant that demonstrate that the applicant meets the qualifications noted above.

COUNTY VETERANS SERVICE OFFICE REPRESENTATIVE'S SIGNATURE

DATE

COUNTY VETERANS SERVICE OFFICE REPRESENTATIVE'S PRINTED NAME

TITLE

If this form is being submitted for an application for disabled veteran license plates only, this form and all other requirements, including acceptable proof of true full name and date of birth, may be submitted in person or by mail . For more information, please visit www.dmv.ca.gov.

FOR DMV USE ONLY

TECHNICIAN'S INITIALS/TECH ID #

DATELINE STAMP

APPLICANT'S DL/ID NUMBER

VSD-001 (Rev. 1/2021)

This form is not transferable

How to Edit Vsd 001 Form Online for Free

Having the goal of allowing it to be as effortless to operate as possible, we generated the PDF editor. The process of filling up the vsd001 can be simple in the event you check out the next steps.

Step 1: On the following webpage, hit the orange "Get form now" button.

Step 2: After you have entered the editing page vsd001, you should be able to find all the functions intended for your file at the top menu.

The following sections will compose the PDF template that you will be filling in:

step 1 to completing form vsd001

Type in the required data in TECHNICIANSINITIALSTECHID, FORDMVUSEONLYDATELINESTAMP, APPLICANTSDLIDNUMBER, VSDRev, and Thisformisnottransferable section.

TECHNICIANSINITIALSTECHID, FORDMVUSEONLYDATELINESTAMP, APPLICANTSDLIDNUMBER, VSDRev, and Thisformisnottransferable in form vsd001

Step 3: Press the Done button to be certain that your finished form can be transferred to every gadget you pick out or delivered to an email you specify.

Step 4: You will need to create as many copies of your document as possible to keep away from future worries.

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