PERSONAL DETAILS Full Name Date of Birth* NHS Number Telephone Email Address Postal Address Postcode Current Occupation MILITARY SERVICE DETAILS Service Number Division/Regiment(s) Enlistment Date Discharge Date Are you in receipt of a War Disablement If Yes, for what or Armed Forces Yes | No was it awarded? Compensation Scheme Payment? MEDICAL INFORMATION Do you wear hearing If Yes, how were Yes | No NHS | Private | MOD aids / hardware now? these funded? Name and Address of Dispenser / NHS Postcode Date of Last Appointment VETERAN’S DECLARATION declare that the information I have given is correct to the best of my knowledge. I consent “I to the details provided being used by TRBL on my behalf to request my Service history and medical records from appropriate agencies (eg, MOD). I consent to the full medical records being disclosed to TRBL for the purpose of assessing my eligibility to the Veterans Medical Fund.” Signature Date
PERSONAL DETAILS Full Name Date of Birth* NHS Number Telephone Email Address Postal Address Postcode Current Occupation MILITARY SERVICE DETAILS Service Number Division/Regiment(s) Enlistment Date Discharge Date Are you in receipt of a War Disablement or Armed Forces Compensation Scheme Payment? Yes | No If Yes, for what was it awarded? MEDICAL INFORMATION Do you wear hearing aids / hardware now? Yes | No If Yes, how were these funded? NHS | Private | MOD Name and Address of Dispenser / NHS Postcode Date of Last Appointment VETERAN’S DECLARATION “I declare that the information I have given is correct to the best of my knowledge. I consent to the details provided being used by TRBL on my behalf to request my Service history and medical records from appropriate agencies (eg, MOD). I consent to the full medical records being disclosed to TRBL for the purpose of assessing my eligibility to the Veterans Medical Fund.” Signature Date
veterans-hearing-fund-eligibility-application-form.docx