Veterans Housing Navigator Registration Form

1000 W Stanton Street
Roseburg, OR 97471

Phone: (541) 673‑6548
Fax: (541) 673‑8230
TTY: (800) 735-2900

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Veterans Housing Navigator Registration Form

This form collects basic information from U.S. Veterans who are interested in case management services through the Veterans Housing Navigator Program. The case manager will contact you to schedule an intake meeting. If a waitlist for services develops, you will be placed on the waiting list based on the date and time of your application. Veterans who are currently homeless or at eminent risk of homelessness may be selected from the waiting list before those at lower risk of homelessness.

Contact Information

Legal Name(Required)

First Last

Mailing Address(Required)

We must have a mailing address for all correspondence related to the Veterans Housing Navigator program.

Street Address Address Line 2 City State ZIP Code

Physical Address

Enter a physical address if it is different from your mailing address.

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Alternate or Message Phone

Enter a secondary phone number, if available.

Preferred Contact Methods(Required)

Please select how you prefer to be contacted. You may select multiple options. Some information will be sent by U.S. mail regardless of preference.

Call

Text

Mail

Preferred Contact Days and Times

Please indicate if you have days and times when you prefer to be contacted.

Service Record

Branch of Service(Required)

Please select your branch of service.

Service Start Date(Required)

Service End Date(Required)

Were you on Active Duty for at least one day during your service period?(Required)

Yes

Discharge Status(Required)

Please enter the discharge status listed on your DD-214.

Housing Goals

Please briefly describe your housing goals and any related goals.(Required)

Housing goals can be finding housing, applying for housing, dispute resolution with a landlord, preventing homelessness, etc. Related goals, like increasing income, are those intended to help you reach and maintain your housing goals.

This field is for validation purposes and should be left unchanged.

The Housing Authority of Douglas County does not discriminate on the basis of sex, race, religion, national origin, age, sexual orientation or gender identity, color, familial status, disability, marital status, or source of income.