Bremer County Veterans Affairs Transportation Request
Complete the following form and a representative of Bremer County Veterans Affairs will contact you to verify your appointment.  Please be advised that Bremer County Veterans Affairs must have a copy of your DD-214 (discharge papers) on file before we can transport you.  We can help you obtain these.


Please be advised that this form should only be used if filled out AT LEAST five days prior to your scheduled appointment.  If your appointment is less than five days away, call our Transportation Coordinator at (319) 596-5800 as soon as possible so that we may try to schedule your trip.
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Veteran Name *
Contact Telephone Number *
E-mail Address
Last Four of the Veterans Social Security Number
If you do not feel comfortable providing this information through this form, leave this answer blank and our Transportation Coordinator will contact you.
Home Address *
City *
Zip Code *
Do you require a home pickup? *
We can only provide this service to veterans without transportation or, because of a disability, are no longer able to drive.
Date of Appointment (mm/dd/yy) *
If you have appointments on more than one day, please complete a form for each day.
Destination *
Time of Appointment & Clinic Visiting *
Type the time of ALL your appointment(s) below and the clinic(s) you will be visiting (ie Radiology, Lab, etc.)
Do you require or wish to have an escort travel with you? *
Your Escort's Name
Only required if you answered yes to the above question.
Comments
Please leave any information necessary for us to make your trip a successful one.  If you have special requests or questions, please leave them here.
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