Phone/Fax: 1-310-532-0634

Coast Guard Restricted Duty
Replacement Recognition Application Form

INSTRUCTIONS:

    1. Complete this form in full.
    2. Print and mail or fax this completed form, along with a copy of your or the veteran's DD-214 or other pre-arranged military document(s) to the address below.

    Charge card or Debit card applicants: To expedite shipment of your Replacement Recognition you may email this form today. Your Replacement Recognition will be prepared and awaiting the arrival of your DD-214 or other, pre-arranged military document(s).

    Recipient's LAST Name:
    FIRST Name:
    MIDDLE name:
    Title (Must appear on military documentation):Jr Sr II III IV

    Rank Title (Please Do Not Abbreviate):

    Paygrade
    Enlisted
    Warrant
    Officer

    Street Address:

    City:
    State:
    ZipCode:
    Phone:

    Full and complete contact email address:

    Recipient's Service Number:

    This section for Charge Card and Debit Card applicants. If you are sending a check or Money Order please skip this section:

    Your Name as it appears on your charge or check debit card:

    Payment Method
      Check Debit
      Visa
      MasterCard
      American Express
      Diners Club
      Carte Blanche

    Card number:
    Expiration Date

    If you mail this form, please sign here:

    International shipping cost (U.S. veteran living outside the United States, please add the shipping cost you were quoted...)

    Total Admin Processing/Delivery:

  • .PDF Emailed - $9.50 Black & White (No Color)
  • U.S. delivery - $21.10 Document Only
  • U.S. delivery - Bond Enclosure $25.60
    Navy
    Regal
    Black
    Military Standard Issue
  • U.S. delivery - EnDurable Frame, Acrylic Brown, $27.60
  • U.S. delivery - EnDurable Frame, Acrylic Black, $27.60
  • U.S. delivery - Gold Color Frame, $32.60 Gold
  • I do not want the Display Recognition. I am requesting the hardware items (medal, badge, ribbon or patch) if they are available for this award, below. (Additional shipping cost applies to non-certificate requests.)

    • Would you like a published copy of My Military Medal Last Will And Testament?

    • Yes, please include a Medal Will for a male heir of my medals and add $4.00 to my total

    • Yes, please include a Medal Will for a female heir of my medals and add $4.00 to my total

    • No, I will obtain the free jpg copy

      • Would you like to track your package through the United States Post Office (http://www.usps.com/shipping/trackandconfirm.htm?from=global&page=0035trackandconfirm/trackandconfirm.htm?from=global&page=0035trackandconfirm) after it has been shipped (for sixty-five [.65] cents extra)?

    • Yes, add 65 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 fax a copy of your military document(s).

      Records Chief (REC-AMW)
      The American War Library
      Building Two, 16907 Brighton Avenue
      Gardena CA 90247-5420
      Phone/Fax: 1 310 532 0634