2. Personal Information
4. Name of Veteran:*
5. Date of Birth:*
   Date of Birth:
6. Gender:*

   1. Male
   2. Female
8. Phone Number:*
9. Email Address
11. Home Address (Street):*
13. City*
14. State*
15. Zip Code:*
17. Military Information:
19. Branch of Service:*
20. Rank at Discharge:*
22. Original Date of Enlistment: *
    Original Date of Enlistment:
23. Date of Discharge (if applicable):
    Date of Discharge (if applicable):
25. Please indicate any special status(es) obtained:

    1. MIA
    2. KIA
    3. Purple Heart
    4. Other
26. If "other," please explain:
28. List any decorations and citations:
30. Check all that apply:*

    1. Active Duty
    2. Guard
    3. Reserves
31. List any conflicts served in (WWI, WWII, Korea, Vietnam, Peacetime, etc.):
33. Military Occupational Specialties or Qualifications:*
34. Would you be willing to discuss experiences while you were in service?*
    -- Select One --YesNo
36. Each application must be submitted with a copy of one of the following documents: DD214 (preferred), Honorable Discharge Certificate, Assignment Orders, or other verification of Service*
37. If you submitted alternative verification of service, please explain:
39. Additional Document
41. Additional Document
43. If you have additional documents you would like to submit, please email to jane.robertson@edmondok.com
45. Contact Information for Person Submitting Application (if not Veteran named above):
47. Full Name:
48. Phone Number:
49. Email:
51. Address:
52. City
53. State:
55. Relationship to Veteran Listed Above:
57. By checking "Yes," I certify that I have permission of the above-named Veteran or Veteran's family (if deceased) to submit this application for inscription.*

    1. Yes
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field