California Department of Veterans Affairs

Headquarters Admissions Office

1227 O Street, Suite 324

Sacramento , CA 95814

                                                                    (916) 651-3049

STATEMENT OF INTENT TO APPLY

I intend to apply for admission to the new Veterans Homes of California in Redding.                          

Please send an application package to me at the following address:

_____________________________________________________________________________________

Last Name                              First Name                               Middle Initial (please print)

_____________________________________________________________________________________

Number                                   Street                                       Apt. /Space (please print)

_____________________________________________________________________________________

City                                          State                                        Zip Code (please print)

My telephone number is: (_______)_______________________

Signed: _________________________________________________ Date: _________________________

You must notify our office of any change of address.

Please mail this Statement of Intent to Apply to the California Department of Veterans Affairs at the address at the top of this form. You can also deliver the form to our office in person.

Do not e-mail or fax this form.