Questions About This Form? Use Email

Republic of Vietnam
1. Life Saving Medal
2. Public Health Service Medal
Replacement Recognition 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, or you can Print and mail this form along with a copy of the DD-214, WD AGO 53-55, NAVPERS 553, NGB or other pre-arranged documents to the Library's mailing 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.

Certificate Type:

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

Is this veteran currently living, deceased or KIA:
  LIVING
  DECEASED
  KILLED IN ACTION

Rank Title (Please Do Not Abbreviate):

Paygrade
Enlisted
Warrant
Officer

Date of humanitarian service rendered:

Location of event:

I have not moved. My current address info is on file from a previous application

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

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  

    • 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 ($24.77)...
       Document only with wallet card ($30.77)
  • Document shipped in Bond Enclosure ($29.77)...
       Document in Bond Enclosure with wallet card ($35.77)

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

    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: $3.77) 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

    • Ignore this final Question if you will EMAIL or have previously EMAILED a copy your DD-214...

    Would you like your mailed DD-214 scanned by The War Library and integrated into your 201A Award Report that will be emailed to you when your requested item(s) are sent to you? The scanning fee is $3.00 (a one-time fee)

  • Yes, add a one-time $3.00 to my total to Scan and Integrate my DD-214 into my Award Report
  • No, I will accept my Award Report without my DD-214 appearing in the Report

    • 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..

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