Board of Chosen Freeholders
County of Burlington
New Jersey
VETERANS SERVICES
HUMAN SERVICES FACILITY
795 WOODLANE ROAD
WESTAMPTON, NJ
Mailing Address
P.O. BOX 6000
Mt. Holly, NJ 08060-6000
(609) 265-5008
(609) 265-5247
FAX (609) 265-3184
APPLICATION FOR THE BURLINGTON COUNTY
MILITARY SERVICE MEDAL
Sponsored by The Board of Chosen Freeholders
Please complete this application form and return it with a copy of your discharge/separation papers: DD-214 or
WD-AGO 53-55. Application must be complete or it will not be accepted.
APPLICATIONS ARE FOR BURLINGTON COUNTY RESIDENTS ONLY.
1. Name (Last, First, M.I.)
2. Social Security Number
3. Rank/Grade Held Upon Discharge
4. Address
5. Branch of Service
6. Era of Service: WII
Korea
Vietnam
Persian Gulf
Other
7. Dates of Service
8. Date of Birth
9. Daytime Phone Number
POSTHUMOUS AWARD:
Yes
No
10. Name of Person to Receive Award
11. Address
12. Daytime Phone Number
Relationship
POSTHUMOUS AWARDS ARE FOR VETERANS WHO WERE RESIDENTS OF BURLINGTON COUNTY
AT THE TIME OF DEATH.
Signature
Date
ALL MEDALS WILL BE PERSONALLY PRESENTED.
RETURN APPLICATION TO:
NO MEDALS WILL BE MAILED.
Military and Veterans Services
County of Burlington
P.O. Box 6000
Mt. Holly, NJ 08060-6000
Print Form