National Personnel Records Center (MPR)
9700 Page Avenue
St. Louis, Missouri 63132

Dear National Personnel Records Center (MPR),

I hereby authorize the National Personnel Records Center, or other custodian of my military service record, to release to ...

NAME
MAILING ADDRESS
CITY, STATE, ZIP CODE

... the following information and/or copies of documents from my military service record.

SPECIFY THE INFORMATION AND/OR DOCUMENT(s) REQUESTED

_________________________________       __________
 Veteran's signature                  Date

Veteran's name
Mailing address
City, State, Zip Code
Phone number (optional)
Branch of service
Date of birth
Service number
Social Security Number
Dates of service (from MM/YY to MM/YY)