Military Record Order Form

Name Used During Service: First name Middle name Last name Birth Date -Month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -Day- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -Year- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000   County of birth State of Birth -Select- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Other Military Service Please include all service including Reserve and IRR as this affect where your record may be located. Dates of Service Check One Branch of Servive Date Entered Date Released Officer Enlisted Service Number Active Service Reserve Service National Guard Choose One Undeleted Report of Separation Deleted Report of Separation Other information or documents requested: Purpose (optional): Requestor is: Choose One Military Service Member or Veteran listed above Next of Kin of Deceased Veteran Legal Gaurdian ( must show proof) Other   If the veteran is living, but does not sign this order form, you must attach a copy of the POWER OF ATTORNEY that authorizes you to act on the Veterans behalf. Specify Person if Other is choosen above: First name: Last name: Mailing Address: * Apartment No: City: State: -Select- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: Tel: E-mail: I declare ( or certify verify or state ) under penalty of perjury under the laws of the United States of America that the informatiom on requester and authorization to this document is true and correct Signature:_________________________________ Date: I authorize I have read and understand the fees listed below.