To: The Department of Defense, Veterans and Emergency Management
Maine Veterans’ Services
117 State House Station
Augusta, Maine 04333-0117
Phone: (207) 430-6035
Fax: (207) 626-4471
WOMEN VETERANS’ SILVER COMMEMORATIVE COIN
VETERAN INFORMATION
LAST NAME: _________________________________FIRST NAME: ________________________MI:_____
LAST NAME(S) SERVED UNDER:____________________________________________________________
SVC#:________________________
DOB:___________________
DISCHARGE DATE: ___________ RANK:____________ TYPE OF DISCHARGE: _________________
(must be Honorable or equivalent to qualify)
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) ____________________________
EX-POW
If home of record other than Maine at time of entry, how many years have you been a resident of Maine?__________
Veterans Address
:
______________________________________________________
Town
: ____________________________
ZIP Code: ___________________
PHONE#:_________________________
EMAIL:______________________________
________________________________________________
VETERAN’S SIGNATURE /DATE REQUIRED HERE)
PLEASE ATTACHED A COPY OF DD-214(s) OR MILITARY DISCHARGE
AND MAIL TO MAINE VETERANS’ SERVICES
PLEASE CIRCLE APPROPRIATE LOCATION
____ I will pick up my silver commemorative coin at the nearest Maine Veterans Services
Office
(circle office closest to you) Augusta Bangor Caribou Lewiston Machias
Portland Springvale Togus Waterville