WHEN COMPLETED Please email this form back to [email protected] MAKE A VETERAN SMILE PROGRAM APPLICATION Are You Eligible? To be considered for financial aid and other services from the Coalition, applicants must meet the following minimum eligibility requirements: • An injury sustained during combat in Operation Iraqi Freedom or Operation Enduring Freedom, Operation New Dawn or in support of those operations in a hostile environment; • A disability rating assigned by the Department of Defense or the Department of Veterans Affairs of 30 percent or greater from a single, sustained injury; • Currently experiencing severe financial hardship; • Located within 200 miles of Annapolis, MD where the treatments would take place. • Completion of a Coalition to Salute America’s Heroes aid application and timely submission of supporting documentation as requested; and IF YOU MEET THE ABOVE, Please complete the following, and e mail with photo to [email protected] Name: Address: Gender: Age: Military service history (OIF/OEF/OND/ongoing, dates of entry & discharge):