Application For Award / Program - State Of New Jersey

NEW JERSEY DEPARTMENT OF MILITARY & VETERANS AFFAIRS

APPLICATION FOR AWARD / PROGRAM

INSTRUCTIONS

•Print or type information. • Attach a copy of DD Form 214 or WD Form 53 • Attach a copy of death certificate (if applicable)

• Mail to: NJ Dept of Military & Veterans Affairs, ATTN: DVS-VBB (Awards), PO Box 340, Trenton, NJ 08625-0340

• For further information - Phone 609-530-6954

• Any missing information your request will not be processed

Program or Award Requested:

(Check all that apply)

NJ Distinguished Service Medal

NJ Vietnam Service Medal

NJ POW/MIA Service Medal

NJ Meritorious Service Medal

NJ Korean Service Medal

VETERAN'S INFORMATION

1. Name (Last, First, Middle Initial)

2. Service Number / SSN

3. Rank/Grade Held Upon Honorable Discharge

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4. Address:

Street: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Apt . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Residency Upon Entry on Active Duty:

City: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . . . . . Zip Code . . . . . . . . . . . . . . .

City: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Home Phone: (. . . . . . ) . . . . . . . . . .. . . . . . . . . . . . . . . . . . .

Business phone: (. . . . . .). . . . . . . . . . . . . . . . . . . Cell Phone: (. . . . . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

State: . . . . . . . . . . . . . . . . . .

E-Mail Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MILITARY SERVICE INFORMATION

6. Branch of Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Army, Navy, Air Force, Marine Corps, Coast Guard, Merchant Marine)

7. War Time Service (Check all that apply)

World War I

World War II

Korean War

Vietnam War

Desert Shield/Storm

Enduring Freedom

Iraqi Freedom

8. Type of Combat

Ground

Air

Sea

8a. Theater of Operations: (Check all that apply)

European-African-Middle Eastern

Asiatic Pacific

North Atlantic

American

Southeast Asiatic

Southwest Asiatic

9. What Veteran's Organizations do you belong to? (If any). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

POSTHUMOUS AWARD

YES

NO

) (Attach copy of Death Certificate)

(If YES - Complete the following

10. Name of Person to Receive Award (Last, First, Middle Initial)

Relationship to Deceased Veteran

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11. Address

Street . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . . Zip Code . . . . . . . . . . .

Home Phone: (. . . . . .) . . . . . . . . . . . . . . . . . . . . . . . . Business Phone: (. . . . . .) . . . . . . . . . . . . . . . . . . . . . . . Cell Phone: (. . . . . .) . . . . . . . . . . . . . . . . . . . . . . . . . .

E-Mail Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12. Presentation Ceremony

Requested

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□

SIGNATURE: . . . . . . . . . . . . . . SIGNATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date . . . . . . . . . . . . . . . . . . . . . . . . . .

YES

NO

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For Use by Approving Authority: NJ Dept of Military & Veterans Affairs:

D

DMAVA Form 416

Revised September 2011