Operation Medic Injury Treatment and Compensation Sign Up
Filling out this form is the first step in the intake process for Operation Medic. After completing intake, someone will reach out to you and complete the program intake. No One Left Behind cannot guarantee whether the law firm will take your case, how long it may take for the law firm to handle your case, or what sort of treatment and compensation you will be eligible for.
First Name *
Your answer
Last Name *
Your answer
E-Mail Address *
Your answer
Phone Number *
Your answer
Country of Origin *
Native Language *
Current Country of Residence *
Current State of Residence *
What American military contractor(s) did you work for? *
For example, Mission Essential Personnel (MEP), L3 Communications, Blackwater, etc.
Your answer
What dates did you work for those companies? *
Your answer
What injuries did you sustain while working with the US military? *
For example, shrapnel wounds, gunshot, concussion, depression, head injuries, burns, hearing loss, damage to sight/blinding, etc.
Your answer
Will you need an interpreter in your native language for your intake appointment?
Submit
Never submit passwords through Google Forms.
This form was created inside of No One Left Behind. Report Abuse - Terms of Service - Additional Terms