Is this veteran currently living, deceased or KIA:
KILLED IN ACTION
Persian Gulf Campaign Veterans Only: Service Branch:
Air Force Reserve
Coast Guard Reserve
Persian Gulf Campaign Veterans Only: Rank Title (Please Do Not Abbreviate):
I have not moved. My current address info is on file from a previous application
Phone ( NO SPACES OR DASHES):
Your full and complete contact email address:
SERVICE NUMBER: Enter the veteran's FIRST FOUR DIGITS ONLY (Do Not enter any alphabet letters. Numbers only.)
SECOND FOUR (or remaining) DIGITS ONLY
Persian Gulf Campaign Veterans Only: Date Arrived Southeast Asia Territory:
Persian Gulf Campaign Veterans Only: Date Departed Southeast Asia Territory:
PERSIAN GULF CAMPAIGN VETERANS ONLY: UNIT / VESSEL INFORMATION
The name/number of your Company or Vessel:
If your unit was part of a Battalion what is the name/number of your Battalion:
If your unit was part of a Regiment what is the name/number of your Regiment:
If your unit was part of a Brigade or Air Group what is the name/number of your Brigade or Group:
If your unit was part of a Division or Air Wing what is the name/number of your Division or Wind:
If you are sending a Check or Money Order please indicate:
CHARGE or DEBIT CARD applicants:
-- My current Card information is already on file from a previous Application
If your Card information is not on file, please Complete the following...
International shipping cost (
U.S. veteran living outside the United States, please add the shipping cost you were quoted...
TOTAL ADMIN PROCESSING/DELIVERY :
I want to purchase the Full Color...
PDF emailed ($7.50) (No shipping fee)
Document shipped ($25.60)... Document only with wallet card ($31.60)
Document shipped in Bond Enclosure ($30.60)... Document in Bond Enclosure with wallet card ($36.60) (The shipping totals above include the USPS - Priority Mail shipping fee)
Would you like an archive (black&white) copy of the Certificate you are applying for to be mailed from the Records Chief directly to your Commanding Officer -or- to your Employer -or- to your School Administrator for inclusion into your permanent personnel file jacket?
(Fee: $3.50) Available only when a published certificate is requested. Not available with emailed certificates. No.
Yes, please mail an embossed, B&W copy of my Certificate to the following person and address:
Official's Agency Name (name of unit, vessel, office, school, etc.)
City, State, Zip
Would you like to track your package through the
United States Post Office after it has been shipped (for twenty [.20] cents extra)?
Yes, add 20 cents to my total
No, I don't want to track my package
Click Here if you are a Prior Applicant who's DD-214 is on file
New Applicants Click Here
Your Application Form is now complete. Print, Sign and Mail this completed form to the address below along with the required military-issued Report of Separation or other (pre-approved) document(s). You may (OPTIONAL) email this form for faster processing. However, you must still mail or email a copy of your military document(s).