Fillable Printable Application for Award / Program - New Jersey
Fillable Printable Application for Award / Program - New Jersey
Application for Award / Program - New Jersey
NEW JERSEY DEPA RTMENT O F MILITARY & VETERANS A FFAIRS
APPLICATIO N FOR AWARD / PROGRAM
INSTRUCTIONS
•P
rint or type information. • Attach a copy of DD Form 214 or WD Form 53 • Attach a copy of death certificate (if applicable)
• Mail to: NJ Dept o f Milit ary & Veterans Affairs, ATTN: DVS-VBB (Awards), PO Box 340, Trenton , NJ 08625-0340
•
For further information - Phone 60
9-530-6954
• Any mis s ing information your request will not be proce s sed
Progra m o r Award Request ed:
(Ch eck all t ha t apply)
NJ D istinguished Service Medal NJ Vietna m Service Medal NJ POW/MIA Service Medal
NJ Meritorious Service Medal NJ Korean Service Medal
VETERAN'S INFORMATION
1. Name (Last, Fir st, Middle In it ial)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 .
S
ervic e N um ber / S SN
. .
. . . . . . . . . . . . . . . . . . . . . . .
3.
R
ank/Grade Held Upon Honorable Discharge
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Address:
Street: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Apt . . . . . . . . . . . . . . . . . . . . . . . . . .
City: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . . . . . Zip Cod e . . . . . . . . . . . . . . .
Count y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hom e Pho ne: (. . . . . . ) . . . . . . . . . .. . . . . . . . . . . . . . . . . . .
Business phon e: (. . . . . .). . . . . . . . . . . . . . . . . . . Cell Phone: (. . . . . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E
-Mail Add r ess: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
.
R
esidency Upon Entry on Active Duty:
City: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
State: . . . . . . . . . . . . . . . . . .
MIL I TARY SERVICE I NFORMATION
6
.
B
ranch o f Servic e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Army, Navy, Air Force, Marine Corps, Coast Guard, Merchant Marine)
7 . Wa r Tim e Servic e (Chec k al l th at apply)
World War I World War II Korean War Vietnam War Desert Shield/Storm Enduring Freed om Ir aqi Freedom
8. Type of Combat
Ground Ai r Sea
8 a. Theater of Opera tions : (Check all that apply)
European-African-M id dle East er n Asiatic Pacific North Atlantic American Sou theast Asiatic Southwest Asiatic
9. W
hat Veteran's Organizations do you belong to? (If any). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
POSTHUMOUS AWARD YES NO (If YES - C om p lete the follow ing) (Attach copy of Death Certificate)
1 0 . Name o f Perso n to Receive Awa rd (Last, First, Middle Initial) R elations h ip to Decea sed Veter an
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
1.
A
ddres s
Street . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State . . . . . . . . . . Zip Code . . . . . . . . . . .
Home Phone: (. . . . . .) . . . . . . . . . . . . . . . . . . . . . . . . Business Phone: (. . . . . .) . . . . . . . . . . . . . . . . . . . . . . . C ell Phone: (. . . . . .) . . . . . . . . . . . . . . . . . . . . . . . . . .
E-Mail Address : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SIGNATURE: . . . . . . . . . . . . . . SIGNATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . .
Date .
. . . . . . . . . . . . . . . . . . . . . . . . .
For Use by Approving Authority: NJ Dept of Military & Veterans Affairs:
D
DMAVA For m 416 Revised Sept ember 2011
1 2 . Presen tatio n Ceremony
Requested
□YES □NO
ELIGIBILITY CRITERIA:
NJ Distinguished Service Medal
-Veterans of the Armed Forces of the United States who served in
time of war or national emergency in a combat theater of operation.
-Current or past resident of NJ for a minimum of 20 years.
-Resident of NJ upon entry on Active Duty.
-Posthumous award authorized.
NJ Vietnam Service Medal
-Current Resident of NJ.
-Served on Active Duty on or after Dec. 31, 1 960 and on or before
May 7, 1975 i n Vietnam; Thailand, Laos, Cambodia (or contiguous
waters or airspace).
-Posthumous award authorized.
NJ Meritorious Service Medal
-Veterans of the Armed Forces of the United States who served in
time of war or National emergency in a combat theater of operation.
-Non-Resident of NJ upon entry on Active Duty.
-Current Resident of NJ, having resided in NJ for at least the past 5
years.
-Posthumous award authorized.
NJ Korean Service Medal
-Current Resident of NJ.
-Served on A ctive Duty on or after June 23, 1950 and on or before
January 31, 1955 in Korea, or contiguous waters or airspace thereof;
and.
-Posthumous award authorized
NJ POW/MIA Service Medal
-Current resident of NJ
-Resident of New Jersey upon entry on Active Duty
-Served in a combat theater and was officially listed as a prisoner of
war or missing in action by the US Dept of Defense.
-Posthumous award authorized
NOTE: An honorable discharge is a mandatory requirement for any New Jersey state award.
APPLICATIO N PROCE DURE:
Complete and sign application on front side of this form.
Provide a copy of: (DO NOT SEND ORIGINALS)
__ Proof of residency (Any document showing name and home address)
__ DD Form 214 indicating Honorable Discharge
__ Evidence of active duty service in qualifying areas or contiguous waters or airspace
__ Evidence of status as POW or MIA
Submit completed application and documents to:
The Adjutant General
New Jersey Department of Military & Veterans Affairs
ATTN: DVS-VBB (Awards)
PO Box 340
Trenton, NJ 08625-0340
