Name:
Service No.:
Date of Birth:
Dates of service: (beginning and ending)
City/state of residence:
Date of above address:
Dependants:
Duty status:
Marital status:
Rank/grade:
Salary:
Assignments & geographical locations:
Education level: Military:
Education level: Civilian:
Decorations & awards:
Transcript of court martial/trial: (if any)
Photograph: (if any)
Place of entry:
Place of separation:

If the person named above is deceased,
(you must provide a death certificate)
the following info may also be released.

Place of birth:
Last known street address:
Date and location of death:
Place of burial: