U.S. Deopartment Of Veterans Affairs 2346 VA2346

User Manual: 2346

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REQUEST FOR HEARING AID BATTERIES & ACCESSORIES
NOTE: If mailing this form, place in an envelope and mail to:
Department of Veterans Affairs
Denver Distribution Center (905A)
P.O. Box 25166
Denver CO 80225-0166
NOTE: If attaching this form to an e-mail, send to:
ddc.css@va.gov
1. LAST NAME - FIRST NAME - MIDDLE INITIAL 2. LAST FOUR DIGITS OF YOUR
SOCIAL SECURITY NUMBER
3. DATE COMPLETED
(MM/DD/YYYY)
4. HOME ADDRESS (Street No., City, State, and ZIP Code) 5. THIS ADDRESS IS:
PERMANENT
NEW
TEMPORARY
NOTE: The Denver Distribution Center will send a six months supply of batteries for the following hearing aids:
6. HEARING AID INFORMATION
TRADE NAMEa.
MODELb.
SERIAL NUMBER(S)c.
NUMBER OF HOURS PER
DAY HEARING AID(S) USED
d.
BATTERY SIZEe.
ACCESSORIESf.
7. REMARKS
VA FORM Adobe Forms Designer 6.0
DEC 2001 (R) 2346 (Electronic version)
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U.S. Deopartment of Veterans Affairs Document: VA2346: Free Downloads

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