Form No number - online No number - online Camp Lejeune Notification Registry form

Camp Lejeune Notification Registry
Personal Info:
* Last Name:
* First Name:
* Full Middle Name:

(N/A for no middle name)

Suffix:
* Social Security Number (SSN):

(Ex: 999999999 no dashes or spaces please)

Note: We take your privacy very seriously. For questions about providing your SSN or any other
personal information please refer to our FAQ section or call 877-261-9782 to speak with representative.

Current Address:
* Street:
Apt/Suite #:
* City:
* State:
* Zip Code:
Note: If you live outside of the United States of America, please email your contact information to
[email protected]. You can also contact our toll free call center at 877-261-9782.

Contact Information:
* Primary Phone Number:

(Ex: 999-999-9999)

Email Address:

Your History at Camp Lejeune:
My status while at Camp Lejeune:
I was stationed at Camp Lejeune between 1957-1987.
I worked at Camp Lejeune between 1957-1987.
I resided at Camp Lejeune in Base Housing or Barracks between 1957-1987.
None of the above statements refer to me but I would like information mailed to me.

Dropdown menu:
Not Applicable
Military
Civilian
Contractor
Spouse/dependent
Other

Dropdown Menu:
Newspaper
Magazine
TV
Radio
Poster
Internet Advertisement
Mailing
Blog or Chat Room
Other

How Did You Hear About Us?

If other please specify:

Can you tell us the name of the publication, radio/TV station, website, or other place where you heard about the
Registry?

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