3M Military Veteran Intake Form
This form should only take a few minutes to complete. If you are not sure of your exact dates of service, give your best estimate. Please submit current contact information.
By submitting this form you authorize a military veteran attorney to contact you to discuss your potential claim against 3M. Please provide the best phone number to receive the call.
Submitting this form does not create an attorney-client relationship. No attorney-client relationship exists until you execute a signed retainer agreement with our law firm.
* Required
Email address
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Phone Number
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Branch of Service
*
Choose
Army
Navy
Air Force
Marines
DoD/Civilian
Start of Service
*
MM
/
DD
/
YYYY
End of Service
*
MM
/
DD
/
YYYY
Type of Discharge
*
Choose
Honorable
General
OTH
BCD
Medical Sep./Other
Retired
Deployment History
*
Iraq
Afghanistan
Other Overseas Deployment
Stateside Only
BOOT Camp Only
Required
Did you use reversible earplugs like these at any point during your military service?
*
Choose
Yes
No
Maybe
What was your job in the military (MOS)?
*
Your answer
Do You Have Current Hearing Problems?
Diagnosed Hearing Loss (VA Rating Assigned)
Diagnosed Tinnitus (VA Rating Assigned)
Some Hearing Loss (No VA Rating or VA Denied)
Some Ringing in Ears (No VA Rating or VA Denied)
No Hearing Problem
Not Sure
Other:
Please include anything else you think we should know about you to help evaluate your claim (optional)
Your answer
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