Name:______________________________________________________________

Mailing Address:_______________________________________________________ State:_____________ Zip Code:___________

City:_____________________________ Phone:____________________________ Date:_________________________

Please check Appropriate Dates and Branch of service below:

___*August 2, 1990 to today (Operation Desert Shield/Storm)
___December 20, 1989 to January 31, 1990 (Operation Just Cause - Panama)
___August 24, 1982 to July 31, 1984 (Lebanon/Grenada)
___February 28, 1961 to May 7, 1975 (Vietnam War)
___June 25, 1950 to January 31, 1955 (Korean War)
___December 7, 1941 to December 31, 1946 (World War II)
___April 6, 1917 to November 11, 1918 (World War I)

___US Army
___US Navy
___US Air Force
___US Marines
___US Coast Guard
___US Merchant Marine (eligible only from Dec. 7, 1941 to Aug. 16, 1945)
 

I certify that I served at least one day of active duty during the dates above and was honorably discharged, or am serving honorably.

______________________________________________________________________
Signature of Applicant