Complete this form to connect with the Marine For Life Network representative near you.
DoD ID Number/EDIPI if applicable (found on military ID card):
What state are you located, or relocating to?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
Please provide a detailed description of how we can assist you:
How did you hear about the Marine For Life Network?
Wounded Warrior: If you are seeking assistance with services related to a wound Illness or Injury during your service, contact the Sergeant Merlin German Wounded Warrior Call Center at 877-487-6299.
In accordance with the Privacy Act of 1974 (Public Law 93-579), this notice informs you of the purpose for collection of information on this form. Please read it before completing the form.
AUTHORITY: 10 U.S.C. 5013; 10 U.S.C. 5041; MCO 1754.6C; E.O. 9397, as amended; and SORN M01754-4.
PURPOSE: To provide transition assistance and sponsorship for Marines who honorably leave active service and return to civilian life.
ROUTINE USES: Information will be accessed by Marine for Life Program officials and authorized personnel with a need-to-know to meet the purpose. Information may be disclosed to organizations authorized to provide services and resources under the Marine for Life Program. A complete list and explanation of the applicable routine uses are published in the authorizing SORN available at: https://dpcld.defense.gov/Privacy/SORNsIndex/DODwide-SORN-Article-View/Article/570629/m01754-4/.
DISCLOSURE: Providing information on this form is voluntary, however, failure to provide the information will result in an inability to receive information about the resources you have requested.
RECORD MANAGEMENT: This form shall be managed in accordance with record schedule 1000-34, “General Correspondence (Military Personnel)” of SECNAV M-5210.1.