Form Center

2. Important Information
   This form is for residents of Mansfield, TX who are veterans. The City is creating a database to provide information to veterans on specific events and programs in Mansfield. This form should be completed by the individual whose information is being provided. This information will not be sold to companies or organizations outside the City of Mansfield.
4. First Name of Veteran*
5. Last Name of Veteran*
7. Address*
9. City
10. State*
11. Zip Code*
13. Phone Number*
14. Email Address
16. Branch of Service*
    -- Select One --United States Air ForceUnited States ArmyUnited States Coast GuardUnited States Marine CorpsUnited States NavyUnite States Space Force
17. Years of Service (Ex. '41-'45; YY-YY)
18. Status*
    -- Select One --Active DutyHonorably DischargedReserveRetired
20. Military Rank*
21. Conflict(s) in which you served. (WWII, Vietnam, etc.) If none, leave this field blank.
23. Photo

    If available, please upload a photo of you in uniform during your military service.

24. Please list any service awards or medals you have received.
25. Are you a Purple Heart recipient?
    -- Select One --YesNo
27. Texas Government Code Section 552.024 Public Access Option

    The Public Information Act allows certain current and former government employees and/or officials to elect whether to keep certain information confidential. Unless you choose to keep it confidential, the following information about you may be subject to public release if requested under the Texas Public Information Act. 

    Therefore, please CHECK the items you wish to ALLOW for  public release or choose NONE.

    1. Email address
    2. Home address
    3. Phone number
    4. NONE- I do not want the release of any information.
29. Electronic Certification

    By checking the "I agree" box below, you agree and acknowledge that 1) all provided information is true 2) you have served at least 1 day active military duty and 3) you retired, were honorably discharged, or are actively serving.

    1. I agree.
31. Electronic Signature
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field