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2. Veterans Flag Holder Application
4. Veteran's First Name*
5. Veteran's Last Name*
7. Date of Birth*
   Date of Birth
8. Date of Death*
   Date of Death
10. County of Residence at Time of Death*
12. CEMETERY INFORMATION
14. Cemetery Name*
16. Street Address*
18. City*
19. State*
20. Zip*
22. Section*
23. Range
24. Lot
25. Grave
27. SERVICE INFORMATION
29. War Era Served*
    -- Select One --American Revolution 9/1/1774 - 9/3/1783War of 1812 6/18/1812 - 2/17/1815Mexican American War 4/25/1846 - 2/3/1848Civil War 4/12/1861 - 5/9/1865Philippine Insurrection 2/4/1899 - 7/2/1902Spanish American War 4/21/1898 - 7/4/1902World War I 4/6/1917 - 11/11/1918World War II 12/7/1941 - 12/31/1946Korean Conflict 6/27/1950 - 1/31/1955Vietnam Era 8/5/1964 - 5/7/1975Beirut 8/21/1992 - 9/20/1992Peacetime Service 5/8/1975 - 8/1/1990Persian Gulf War 8/2/1990 - Present
30. Branch of Service*
    -- Select One --AIRFORCE (USAF)ANG Air National GuardAmerican Field Service (WWI/WWII)ARMY (USA)Army NG Army National GuardCOAST GUARD (USCG)Coast Guard Women's Reserve (SPAR)Confederate States ArmyConfederate States NavyForeign Military AllyLighthouse Service (1916-1939)MARINE CORPS (USMC)Merchant Mariner (WWII)NAVY (USN)NOAA Corps (including Coast/Geodetic Survey) Public Health Service (PHS)Revenue Cutter ServiceUSAFR Air Force ReserveUSAR Army ReserveUSCGR Coast Guard ReserveUSMCR Marine Corps ReserveUSNR Navy ReserveWomen's Air Force Service Pilots (WASP)Women's Army Auxiliary Corps (WAAC)Women's Army Corps (WAC)
32. Serial Number*
33. Rank*
35. Enlistment Date*
    Enlistment Date
36. Discharge Date*
    Discharge Date
38. CERTIFICATION
40. I hereby certify that there is no bronze flag holder on the grave at present:
42. Applicant's First Name*
43. Applicant's Last Name*
45. Relationship*
    -- Select One --FatherMotherBrotherSisterSpouse/PartnerFriendNeighborOther
46. Phone Number*
47. Email*
49. Address*
51. City*
52. State*
53. Zip*
55. OTHER
57. Is this request for a replacement flag holder?*
    -- Select One --YesNo
59. Please attach a DD-214 or Military Discharge Record*
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61. 1. Receive an email copy of this form.
62. Email address

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63. Submit Submit and Print

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