Office of Human Resources

I,                                      , declare under penalty of perjury that I am a veteran and/or disabled veteran on the basis of the following:

1. I am a “veteran” as defined in ORS 408.225 (with a discharge or release date of ______________,) because I meet at least one of the following criteria (circle any that apply):
   
   1. I served on active duty with the Armed Forces of the United States for a period of more than 178 consecutive days and was discharged or released from active duty under honorable conditions.
   2. I served on active duty with the Armed Forces of the United for 178 days or less and was discharged or released from active duty under honorable conditions because of a service-connected disability.
   3. I served on active duty with the Armed Forces of the United States at least one day in a combat zone and was discharged or released from active duty under honorable conditions.
   4. I received a combat or campaign ribbon for service in the Armed Forces of the United States.
2. I am a "disabled veteran" as defined in ORS 408.225, because I meet at least one of the following criteria (circle any that apply):
   
   1. I am entitled to disability compensation under laws administered by the United States Department of Veterans Affairs.
   2. My discharge or release from active duty was for a disability incurred or aggravated in the line of duty.
   3. I was awarded the Purple Heart for wounds received in combat.

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT

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Signature                                             Date