REPORT OF U.S. VETERANS ADMINISTRATION
ON APPLICANT CLAIMING PREFERENCE AS DISABLED VETERAN

SOCIAL SECURITY NO.:________________DATE______________

NAME_______________________________________________________

ADDRESS__________________________CITY_____________________

To Massachusetts Director of Standards:

I have this day examined the record of the above-named applicant,
and hereby certify that the answers to the following questions are
true:

  1. Has the above-named applicant a disability incurred in the line

    of duty in the military or naval service of the United States in

    World War 1, World War 11, or Korean or Vietnam Wars?

    YES_________ NO_________

  2. What are the dates of service?

    FROM___________ TO___________

    U.S. Veterans Administration

    By: _____________________

    Title_____________________

I___________________________hereby authorize the release of information to the Massachusetts Director of Standards in order that I may procure a hawker and peddler license.

CONTANT OFFICE: PLEASE RETURN TO VETERAN AFTER CERTIFICATION

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