Questions About This Form? Use Email

Purple Heart Medal, Wound Chevron, Wound Ribbon
Replacement Recognition and Medal Application Form

INSTRUCTIONS:

1. Complete this form in full. ( Click here to email amerwar@amervets.com if you have any technical problems sending this Application Form after you have completed it )

2. Click the button at the bottom of this completed form to email it to The War Library, along with a copy of your or the veteran's DD-214, DD-215, WD AGO 53-55 or other pre-arranged military document(s) to the address below.

Do Not Hilite, Underline, Circle, Colorize
Or Mark In Any Way The DD-214
Or Other Military Document Photocopy
You Will Be Sending.

Charge card or Debit card applicants: To expedite shipment of your Replacement Recognition you may email this form today. Your Replacement Recognition will be prepared and awaiting the arrival of your DD-214, DD-215, WD AGO 53-55 or other pre-arranged military document(s).

1. Select the Award:

2. Recipient's LAST Name (as it appears on the Report of Separation):
FIRST Name (as it appears on the Report of Separation):

MIDDLE name (as it appears on the Report of Separation):
Title (Must appear on military documentation):Jr Sr II III IV

3. Service Branch:

4. Rank Title (Please Do Not Abbreviate):

5. Paygrade
Enlisted
Warrant
Officer

6. Street Address:

City:
State:
ZipCode:
Phone (NO SPACES OR DASHES):

7. Your full and complete contact email address:

SERVICE NUMBER:

  • Enter the veteran's FIRST FOUR DIGITS ONLY (Do Not enter any alphabet letters. Numbers only.) 
  • Enter the SECOND FOUR (or remaining) DIGITS ONLY  

    • 8. Nearest name of City, Area or Geographical Location where wound incident ocurred:

    Date injury or POW incident ocurred:

    If you are sending a Check or Money Order please indicate:

    • I will mail a Check along with my application and documentation. The Library will receive my envelope within 10 days from today.
    • I will mail a Money Order along with my application and documentation. The Library will receive my envelope within 10 days from today.

    CHARGE or DEBIT CARD applicants:

    -- My current Card information is already on file from a previous Application

    If your Card information is not on file, please Complete the following...

    Your Name as it appears on your charge or check debit card:

    Payment Method
      Check Debit
      Visa
      MasterCard
      American Express
      Discover
      Diners Club
      Carte Blanche

    Card number:
    Expiration Date
    Card Verification Number (CVV Code) (See below)
    American Express: 4 digits on front of card
    All other cards, 3 digits on back

    After printing this form for mailing, please sign here:

    International shipping cost (U.S. veteran living outside the United States, please add the shipping cost you were quoted...)

    TOTAL ADMIN PROCESSING/DELIVERY:

    I want to purchase the Full Color...

  • PDF emailed (full color, printable) ($7.50) (No shipping fee)
  • Document shipped ($24.50)...
       Document only with wallet card ($30.50)
  • Document shipped in Bond Enclosure ($29.50)...
       Document in Bond Enclosure with wallet card ($35.50)

    • (The shipping totals above include the USPS - Priority Mail shipping fee)

    Would you like to order the full size Purple Heart replacement medal and/or ribbon?

    • Yes, please include the official medal and add an additional $49.00 to my total
    • Yes, please include the official ribbon and add an additional $4.00 to my total
    • Yes, please include the official medal and the ribbon, and add an additional $53.00 to my total
    • No, I already have the hardwear

    Would you like to receive the Miniature Purple Heart medal?

  • Yes, please include the Miniature medal and add an additional $29.00 to my total.
  • No, I already have the hardwear.

    • Multiple Award Bronze/Silver Star Attachment

  • Yes, please include the 1 Oak Leaf attachment (wounded on two separate occasions) to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total
  • Yes, please include the 2 Oak Leaf attachment (wounded on three separate occasions) to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total
  • Yes, please include the 3 Oak Leaf attachment (wounded on four separate occasions) to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total
  • Yes, please include the 4 Oak Leaf attachment (wounded on five separate occasions) to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total
  • Yes, please include the 1 Silver Leaf attachment (wounded on six separate occasions) to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total
  • Yes, please include the 1 Silver Star attachment to the medal and/or ribbon and add an additional $3.00 (or $6.00 for both medal and ribbon) to my total

    • Would you like an archive (black&white) copy of the Certificate you are applying for to be mailed from the Records Chief directly to your Commanding Officer -or- to your Employer -or- to your School Administrator for inclusion into your permanent personnel file jacket?
    (Fee: $3.50) Available only when a published certificate is requested. Not available with emailed certificates.

  • No.
  • Yes, please mail an embossed, B&W copy of my Certificate to the following person and address:

    • Official's name
    Official's Title
    Official's Agency Name (name of unit, vessel, office, school, etc.)
    Address
    City, State, Zip

    Would you like a published copy of My Military Medal Last Will And Testament?

  • No, I will obtain the free jpg copy

  • Yes, please include a Medal Will for a MALE heir of my Awards and add $4.00 to my total
  • Yes, please include a Medal Will for a FEMALE heir of my Awards and add $4.00 to my total

    • Would you like to track your package through the United States Post Office after it has been shipped (for twenty [.20] cents extra)?

    • Yes, add 20 cents to my total
    • No, I don't want to track my package

    Your Application Form is now complete. After clicking the button below to send this Form you will soon receive a confirmation email containing final instructions on which items, if any, are needed to fulfill your request. Your DD-214 can be mailed or emailed. Non-personalized items such as hardwear may be exchanged or returned within ten days of delivery.

    Records Chief (REC-AMW)
    The American War Library
    817 East Via Carmelitos
    Virginia Building 319
    Long Beach CA 90805-7549
    Phone: 1-562-422-4100 (Pacific Time Zone)

    LINK: Policy Statements On Display Recognitions and Hardwear
    Name-personalized items that are produced uniquely for a recipient may not be exchanged or returned. However, although typographical errors are very rare, there is no time limit on requesting corrections to errors.

    Print a copy for yourself before clicking the bar below..