* indicates a required field
Beneficiary Information
Veteran's First Name
*
Veteran's Last Name
*
Veteran's Branch of Service
Veteran's Phone #
Veteran's Date of Birth
Hometown City
Hometown State
Select . . .
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Veteran's Rank
Health Care Facility Name
Purple Heart Recipient:
Trip Requestor Contact Information
Check if same as Veteran
First Name
*
Last Name
*
Home Phone Number
Preferred
Office Phone Number
Preferred
Mobile Phone Number
Preferred
*At least one phone number is required.
Email Address
*
Relationship
Not Selected
Father
Mother
Sister
Brother
Wife
Husband
Son
Daughter
Aunt
Uncle
Niece
Nephew
Fiance
Veteran
Other
Passenger Coordinator Information
This is the person who will coordinate with the Pilot
Check if same as Trip Requestor
First Name
*
Last Name
*
Home Address
City
State
Select . . .
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Home Phone Number
Preferred
Office Phone Number
Preferred
Mobile Phone Number
Preferred
*At least one phone number is required.
Email Address
*
Passenger List
First Name
Last Name
Age
Relationship
Weight (lbs)
Wheelchair
Phone #
#1
Not Selected
Father
Mother
Sister
Brother
Wife
Husband
Son
Daughter
Aunt
Uncle
Niece
Nephew
Fiance
Veteran
Other
Delete
#2
Not Selected
Father
Mother
Sister
Brother
Wife
Husband
Son
Daughter
Aunt
Uncle
Niece
Nephew
Fiance
Veteran
Other
Delete
#3
Not Selected
Father
Mother
Sister
Brother
Wife
Husband
Son
Daughter
Aunt
Uncle
Niece
Nephew
Fiance
Veteran
Other
Delete
#4
Not Selected
Father
Mother
Sister
Brother
Wife
Husband
Son
Daughter
Aunt
Uncle
Niece
Nephew
Fiance
Veteran
Other
Delete
#5
Not Selected
Father
Mother
Sister
Brother
Wife
Husband
Son
Daughter
Aunt
Uncle
Niece
Nephew
Fiance
Veteran
Other
Delete
#6
Not Selected
Father
Mother
Sister
Brother
Wife
Husband
Son
Daughter
Aunt
Uncle
Niece
Nephew
Fiance
Veteran
Other
Delete
Add Additional Passenger Entry
Travel Needs
Number of Passengers
*
Trip Type
One Way
Round Trip
Origin City & State
Select . . .
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Destination City & State
Select . . .
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Departure Date
Return Date
(leave blank for one-way trips)
Reason for Trip
* Please enter a brief explaination below noting the reason for the travel request along with a short bio. (And any additional information which would be helpful, including travel flexibility.)
VAC Passenger Acknowledgement
I Accept
View Passenger Information
* indicates a required field
Veterans Airlift Command
5775 Wayzata Boulevard, Suite 700
St. Louis Park, MN 55416
952-582-2911
info@veteransairlift.org