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.
Email address *
First Name *
Last Name *
Phone Number *
Street Address *
City *
State *
Zip Code *
Branch of Service *
Start of Service *
MM
/
DD
/
YYYY
End of Service *
MM
/
DD
/
YYYY
Type of Discharge *
Deployment History *
Required
Did you use reversible earplugs like these at any point during your military service? *
Captionless Image
What was your job in the military (MOS)? *
Do You Have Current Hearing Problems?
Please include anything else you think we should know about you to help evaluate your claim (optional)
Submit
Never submit passwords through Google Forms.
This form was created inside of J.P. Joyce & Associates.