Phone/Fax: 1-310-532-0634

Vietnam War 50th Anniversary
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, WD AGO 53-55, NAVPERS 553, NGB 22, 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 or other, pre-arranged military document(s).

    I am applying for...

  • I am authorized the Vietnam Service Medal. I want the 10th Anniversary Display Recognition issued in my name
  • I want the 20th Anniversary Display Recognition issued in my name
  • I want the 30th Anniversary Display Recognition issued in my name
  • I want the 40th Anniversary Display Recognition issued in my name
  • I want the 50th Anniversary Display Recognition issued in my name

  • I am a family member or friend of a Vietnam War veteran. I want the 10th Anniversary Display Recognition issued in the Vet's name
  • I want the 20th Anniversary Display Recognition issued in the Vet's name
  • I want the 30th Anniversary Display Recognition issued in the Vet's name
  • I want the 40th Anniversary Display Recognition issued in the Vet's name
  • I want the 50th Anniversary Display Recognition issued in the Vet's name

  • I did not serve in Vietnam. I want the Un-Named 10th Anniversary Display Recognition as a Historical/Commemorative document to personally honor those who served
  • I want the Un-Named 20th Anniversary Display Recognition
  • I want the Un-Named 30th Anniversary Display Recognition
  • I want the Un-Named 40th Anniversary Display Recognition
  • I want the Un-Named 50th Anniversary Display Recognition

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

    Vietnam Veterans Only: Service Branch:

    Vietnam Veterans Only: Rank Title (Please Do Not Abbreviate):

    Street Address:

    City:
    State:
    ZipCode:
    Phone:

    Full and complete contact email address:

    Vietnam Veterans Only: Service Number:

    Vietnam Veterans Only: Date Arrived Southeast Asia Territory:
    Vietnam Veterans Only: Date Departed Southeast Asia Territory:

    VIETNAM 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 Wing:

    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
  • 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 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)

  • No.
  • Yes, please mail an embossed, B&W copy of my Certificate to the following person and address:

    • Official's name
    Official's Title
    Official's Agency Name (name of unit, vessel, office, school, etc.)
    Address
    City, State, Zip

    Would you like to track your package through the United States Post Office after it has been shipped (for seventy-five [.75] cents extra)?

  • Yes, add 75 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