Vietnam War 50th Commemoration Application

Vietnam War Veterans

50th Commemoration

Application

I. Personal Information:

Veteran's Full Name:*

Family member name and relation: (If the Vietnam Veteran is being awarded posthumously, please list the name and relation of the family member accepting the pin on their behalf.)

Birthdate of Veteran:*

Phone Number:* () -

E-mail:*

Driver's License:*

Would you like to sign up for Congresswoman Castor's e-newlsetter?

YesNo

Home Address:*

Street 1 Street 2 City State Zip

Gender

MaleFemale

II. Service Information:

Branch of Military:*

Dates of Service:*

Location(s) of Service:*

III. Applicant's E-Signature

By signing (typing your legal name) in the space below, you are certifying: I release this information to the Office of Congresswoman Kathy Castor for the use in the Vietnam War 50th Commemoration. I authorize Congresswoman Castor to release my name and photo in all promotional materials (website, e-newsletter, press release, ect.). I am a legal resident of the State of Florida. If I have not submitted ALL required documents by the requested deadline I will not be honored at the ceremony. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application. E-Signature Applicant:*

Our server could not verify that you are a human.

All Veterans will need to submit a copy of their DD-214 to be eligible. DD-214s can be submitted to Congresswoman Castor’s Office via mail, fax or email. If you do not have a DD-214, please fill out the Privacy Release Form below and contact Dewayne Mallory in our office at (813) 871-2817. Obtaining DD-214s can take up to 30 days so please contact our office as soon as possible so we can assist you.

Please click here to complete the Privacy Release Form. Please note our office requires a completed Privacy Release Form for participation in this ceremony.

Applicants can also be submitted to Congresswoman Castor's Office via mail, fax or email. A print version of the application can be found here.

Attention: Dewayne Mallory

Office of Congressman Kathy Castor

4144 N. Armenia Ave Ave Suite 300

Tampa, FL 33607

or via fax at 813.871.2864

or via email at dewayne.mallory@mail.house.gov

You can view Congresswoman Castor's Vietnam War Veterans 50th Commemoration flier here.

Note: Information submitted with your application cannot be returned. Information submitted with your application is subject to the Privacy Act of 1974, 5 U.S.C Section 552(a), as amended and to the Freedom of Information Act, Section 552, as amended.

This office will contact you about how you will receive your pin. Congresswoman Castor will hold events later this year to award these pins, or veterans may have them mailed to them.