Request For Gold Star Honorable Service Medal Form

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To: The Department of Defense, Veterans and Emergency Management
Maine Veterans’ Services
117 State House Station
Augusta, Maine 04333-0117
REQUEST FOR GOLD STAR HONORABLE SERVICE MEDAL
VETERAN INFORMATION
LAST NAME: _________________________________FIRST NAME: ________________________MI:_____
SSN: ___________________________SVC#:________________________DOB:___________________
DATE OF DEATH: ________________
RANK:_____________
BRANCH OF SERVICE:
ARMY
MARINE CORPS
NAVY
AIR FORCE
COAST GUARD
OTHER: ___________________
DATES OF SERVICE:
____________ TO ______________ ; ______________ TO ______________
War Time Service (Check all that apply)
World War II
Korean War
Vietnam War
Desert Shield/Storm
Other (Specify) ____________________________
Applying For:
 Gold Star Honorable Service Medal
(DD-1300 Military Certificate of Death must accompany application)
 Yes or  No, please mail to me.
I would like to attend an award ceremony to receive the above
REQUESTORS NAME: ___________________________________________________________________
Relationship to veteran: ______________________________________
HOME ADDRESS: _______________________________________________________________________
CITY/STATE/ZIP: _______________________________________________________________________
PHONE#:_________________________
EMAIL:______________________________
_______________________________________
YOUR SIGNATURE /DATE REQUIRED HERE)
Signature gives MVS permission to contact DVA if necessary to confirm service and death of individual on active duty
***DO NOT FILL OUT BELOW THIS LINE-OFFICE USE ONLY***
Application # _____________
Date Received _______________ Presented/Mailed ____________________
ELIGIBILITY CRITERIA ON BACK OF FORM

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