Phone/Fax: 1-310-532-0634

Purple Heart Medal, Wound Chevron, Wound Ribbon
Replacement Recognition and Medal 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, DD-215, WD AGO 53-55 or other pre-arranged military document(s) to the address below.

    Do Not Hilite, Underline, Circle, Colorize
    Or Mark In Any Way The DD-214
    Or Other Military Document Photocopy
    You Will Mail.

    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, DD-215, WD AGO 53-55 or other pre-arranged military document(s).

    1. Select the Award:

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

    3. Service Branch:

    4. Rank Title (Please Do Not Abbreviate):

    5. Paygrade
    Enlisted
    Warrant
    Officer

    6. Street Address:

    City:
    State:
    ZipCode:
    Phone:

    7. Full and complete contact email address:

    Recipient's Service Number:

    8. Nearest name of City, Area or Geographical Location where wound incident ocurred:

    Date injury or POW incident ocurred:

    If you are sending a check or Money Order please indicate:

    • I will mail a check along with my application and documentation

    • I will mail a money order along with my application and documentation

    Charge or Debit Card applicants, please complete the following:

    Please choose between ASAP or Monthly shipping...

  • I want the items on this Application Form (and other Forms I am submitting today) to be shipped As Soon As Possible.
  • I want the items on this Application Form (and other Forms I am submitting today) to be shipped in monthly groups of...

      Ship 1 of my Application Forms per month
      Ship 2 of my Application Forms per month
      Ship 3 of my Application Forms per month
      Ship 4 of my Application Forms per month

    Bill my charge/debit card and send me an email receipt between the 1st and 5th day of each month for each shipment. Please note that I am using a credit/debit card that will not expire before all of my monthly shipments have been sent to me.

    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

    After printing this form for mailing, 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:

  • I would like the following Display Recognition...
  • .PDF Emailed - $9.50 Black & White (No Color)
  • U.S. delivery - $21.20 Full Color Document Only
  • U.S. delivery - $25.70 Full Color Document in Bond Enclosure
  • I want ALL or SOME of my Certificates (minimum 20) in pdf format that I can print continuously, shipped to me on a CD rom that I can make copies of. (Library Note: See below for details)
  • I do not want the Display Recognition. I am requesting the hardware items listed below (medal, badge, ribbon or patch) if they are available for this award. (Shipping cost applies to non-certificate requests.)
  • Would you like the full-color Wallet Size Certificate along with one of the above full-size color Certificates ($3.50) Yes No
    I want Certificates in pdf format on a CD rom...

  • I want ALL of my Certificates in full color; $10.00 per Certificate
  • I want SOME of my Certificates (minimum 20) in full color; $10.00 per Certificate; I will be emailing a list of the 20 or more Certificates I want
  • I want ALL of my Certificates in Black&White; $8.00 per Certificate
  • I want SOME of my Certificates (minimum 20) in Black&White; $8.00 per Certificate; I will be emailing a list of the 20 or more Certificates I want
  • No CDrom

    Would you like to order the full size Purple Heart replacement medal and/or ribbon?

    • Yes, please include the official medal and add an additional $28.00 to my total

    • Yes, please include the official ribbon and add an additional $4.00 to my total

    • Yes, please include the official medal and the ribbon, and add an additional $32.00 to my total

    • No, I already have the hardware

    Would you like to receive the Miniature Purple Heart medal?

  • Yes, please include the Miniature medal and add an additional $12.00 to my total.

  • No, I already have the hardware.

    • Multiple Award Bronze/Silver Star Attachment

  • Yes, please include the 1 Oak Leaf attachment (wounded on two separate occasions) to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total

  • Yes, please include the 2 Oak Leaf attachment (wounded on three separate occasions) to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total

  • Yes, please include the 3 Oak Leaf attachment (wounded on four separate occasions) to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total

  • Yes, please include the 4 Oak Leaf attachment (wounded on five separate occasions) to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total

  • Yes, please include the 1 Silver Leaf attachment (wounded on six separate occasions) to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total

  • Yes, please include the 1 Silver Star attachment to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total

    • 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 after it has been shipped (for seventy [.70] cents extra)?

    • Yes, add 70 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. After clicking the grey-bar button below to send this Form you will soon receive a confirmation email containing final instructions on which items, if any, are needed to fulfill your request. (Your DD-214 can be mailed, faxed or emailed).

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