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 *

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 *

Start of Service *

YYYY

End of Service *

YYYY

Type of Discharge *

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? *

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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This form was created inside of J.P. Joyce & Associates.