Louisiana Veterans Honor Medal Application printable pdf download

Louisiana V eterans H onor M edal A pplication

Honoring t he S acrifice a nd S ervice o f O ur V eterans

Eligibility C riteria

• Veteran is a current Louisiana resident, was a Louisiana resident upon entering military service,

or w as a L ouisiana r esident a t t he t ime o f d eath.

• Veteran s erved i n t he U .S. A rmed F orces d uring w artime a nd p eacetime.

• Veteran r eceived a n h onorable d ischarge o r d ied p rior t o s eparation.

• Louisiana N ational G uard/Reservist.

• For m ilitary p ersonal k illed w hile o n a ctive d uty, p lease a ttach f or D D 1 300/Death C ertificate.

• Only o ne m edal p er V eteran/ p er F amily w ill b e a warded.

NOTE: P lease s end O NLY c opies o f s upporting d ocuments, n o o riginals!

LDVA w ill n ot r eturn d ocuments!

Veteran’s I nformation

Name: _ _______________________________________ Date o f B irth: _ ___/____/_____ Gender: M F

Living

Deceased

Purple H eart

Killed i n A ction

POW/MIA

Mailing A ddress: _ ______________________________________________ Parish: _ ________________________

City: _ ______________________________________________________ State: _ _______ Zip C ode: _ __________

Email A ddress: _ ____________________________________________________________________________________

Home P hone: _ _________________________________ Cell P hone: _ ____________________________________

Branch o f S ervice: _ ____________________________ Rank H eld u pon D ischarge: _ __________________

Entered A ctive d uty: _ ___ / _ ___ / _ _______ ( month/day/year) Exited: _ ____ / _ ____ / _ ________

Applicant I nformation

(To b e c ompleted b y t hose a pplying o n b ehalf o f a V eteran)

Name: _ ______________________________________________ Relationship t o V eteran: _ ________________

Mailing A ddress: _ __________________________________________________________________________________

City: _ ______________________________________________________ State: _ _______ Zip C ode: _ __________

Email A ddress: _ ____________________________________________________________________________________

Home P hone: _ _________________________________ Cell P hone: _ ____________________________________

Please c heck y our p reference:

I w ould l ike t o h ave m y m edal a warded t o m e a t a V eteran’s H onor M edal C eremony.

I w ould l ike t o h ave m y m edal m ailed t o m e a t t he a bove l isted a ddress.

I w ould l ike t o r eceive m y m edal a t m y l ocal L DVA P arish S ervice O ffice.

Please m ail c ompleted f orm a nd D D F orm 2 14/ D ischarge P apers t o:

Louisiana D epartment o f V eterans A ffairs, A TTN: H onor M edals A dministrator

P.O. B ox 9 4095, B aton R ouge, L ouisiana 7 0804

Revised 0 1/2017

Louisiana Veterans Honor Medal Application