AFFF Aqueous Firefighting Foam & VA Claim Application

Myself On behalf of a family member

First Name

Last Name

Phone Number

Address

Date of birth

City

State

Zip

Qualifying diseases

Kidney cancer

Testicular cancer

Liver cancer

Thyroid disease

Ulcerative colitis

Thyroid Cancer

When were you diagnosed?

Military/Work exposure:

Are you a current or former member of the U.S. Military?

Yes No

Are you a current or former firefighter or closely associated personnel?

Yes No

Did you use AFFF during your time in the military?

Yes No

Did you use AFFF during your career?

Yes No

Message (max 300 characters)

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AFFF Claim Application Form

Military/Work exposure: