Phone/Fax: 1-310-532-0634

US Vietnam War
Medal of Sacrifice
Replacement Recognition Application Form

INSTRUCTIONS:

    1. Complete this form in full.
    2. Print and email or mail this completed form to the email address or the mailing address below.

    DECEASED VETERAN OR CIVILIAN INFORMATION:

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

    Serial or social security number:

    Rank (please do not abbreviate):

    Service Branch:

    If known, Day, Month and Year of Sacrifice:

    If known, Location of Sacrifice:

    If known, Recipient's military unit, vessel or organization:

    YOUR INFORMATION:

    FIRST Name:
    MIDDLE Name:
    LAST name:

    Street Address:

    City:
    State:
    ZipCode:
    Phone:

    Full and complete contact email address:

    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 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