Nevada Veterans Giveaway Event
NAME (Please Print): ___________________________________________________________________
SEX: M / F AGE:______________________________
ADDRESS:__________________________________ CITY:_________________ STATE:_____ ZIP:_______
BEST CONTACT PHONES:_________________________________________________________________
BRANCH OF SERVICE:_____________________________ SERVICE MOS/AFSC: ____________________
My Priority Needs up to $1000 are: (Please list needed furniture or home goods)
1.)__________________________________________________________________________________
2.)___________________________________________________________________________________
3.)___________________________________________________________________________________
4.)___________________________________________________________________________________
5.)___________________________________________________________________________________
I promise that the merchandise I receive will be used by me and/or my family, and I will not sell any of
the goods that I receive. Once I am approved, I will need to provide some proof of service (i.e. copy of
DD214, VA card, or other form of veteran or military identification).
I also understand and accept that by completing this form, and submitting this form, CityServe and the
sponsoring organizations will do their best to obtain the requested items, but they do not guarantee
performance. If I do not receive all of the requested items, I hereby waive any and all legal rights against
all parties that will attempt to obtain the requested items for me and/or my family.
________________________________________________ __________________________
Signature Date
________________________________________________ __________________________
Form Accepted By: Print Name Date
