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* indicates a required field
Name *

Date of Service *
Select a date from the calendar.
ORGANIZATION *
  Poor Average Excellent 
  12345N/A
First impression/contact 
Office access 
Information available 
SERVICE STAFF *
  Poor Average Excellent 
  12345N/A
Subject knowledge 
Enthusiastic, friendly 
Sincere, considerate, helful 
PROGRAM MATERIALS *
  Poor Average Excellent 
  12345N/A
Harcopy handouts 
Website www.CountyofBerks.com/VA 
PHYSICAL FACILITIES *
  Poor Average Excellent 
  12345N/A
Space 
Parking 
IMPRESSION *
  Poor Average Excellent 
  12345N/A
Your overal impression of service provided to you 
What did you like most about the service you received? *

what did you like least about the service you received? *

Would you recommend Berks County Department of Veterans Affairs to others? *
Please check what is applicable for the person who received service *
  YES NO N/A
  123
Military 
Veteran 
Surviving Family Members 
Applicable branch of service *

Your Recommendations/Improvements for County Government help to Veterans and Families

List your contact information here if you would like to help improve County Government Services to Veterans and Families

Email address