Application for Certificate of Special Congressional Recognition for Service during the Vietnam War

Eligibility for certificate:  Veteran must be alive, reside in the 4^th Congressional District, and must have been eligible to receive either the Vietnam Service Medal, established by Executive Order 11231, or the Armed Forces Expeditionary Medal for service in Vietnam between 1 July 1958 and 3 July 1965.  Provide a legible copy of your discharge document (DD214).

__________________________________________________________________________________(First Name, Middle Initial, Last Name)                                         

(Address and Street Name)                                         

 

 

_____________________________________                      ________________________

(City, State, Zip Code)                                                 (Telephone with area code)

 

__________________________________________________ 

 

SERVICE INFORMATION

 

_____________________________                          ______________________________

(Branch of Service)                                                       (Military occupation during war)

 

 

Please give us information about you that we can read as you accept your certificate.  Tell us where you were stationed during the war.  (Include Division, Battalion, Wing, Squadron, Company, Unit or Group number and Navy and Coast Guard include ship name and number.  Write legibly as information will be read during the ceremony.)

 

 

Mail or fax application to:

Congressman Ander Crenshaw

1061 Riverside Avenue, Suite 100

Jacksonville, Florida 32204

(904) 598-0481 or (386) 365-3316

FAX: (904) 598-0486