Office of Congressman Sean Casten 2020 Application

Vietnam Veteran 50th Anniversary Commemoration Ceremony Date: Sunday, March 29, 2020 Location: Lake Barrington Shores

64 Old Barn Road Lake Barrington, IL 60010

Time: 1:00pm-2:30pm The deadline to submit the completed application and DD Form 214 is March 23, 2020. Please submit this form and all documents to our Illinois district office:

Congressman Sean Casten Attn: 2020 Vietnam Veteran Commemoration Application 800 Roosevelt Road, Building C, Suite 210 Glen Ellyn, IL 60137

If you have access to a scanner, you may email this application to our office: Constituent.ServicesIL06@mail.house.gov.

Please note that per U.S. Department of Defense regulations, “veterans who served on active duty in the U.S. Armed Forces at any time during the period of November 1, 1955 to May 15, 1975, regardless of location, are eligible to receive one lapel pin.” Personal Information Veteran’s Legal Full Name: __________________________________________________________________ (First) (Middle) (Last)

Birthdate of Veteran: __________/__________/__________ (MM) (DD) (YY)

City of Birth: _______________________ Country of Birth: _________________

Veteran’s Current Address: ____________________________________________

City: ________________________ State: __________ Zip Code: _____________

Email:_____________________________ Phone number:___________________

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Office of Congressman Sean Casten 2020 Application

Veteran’s Service Information Branch of Military: __________________________________________________

Military Rank: ⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽⎽

Dates of Service: ________________________ to _________________________

Location(s) of Service: _______________________________________________

If the veteran is deceased, please list the name and relation of the family member or friend accepting the pin on their behalf.

__________________________________________________________________ (First) (Middle) (Last)

_____________________________ (Relation to Veteran)

Relative’s Address: __________________________________________________

City: ________________________ State: __________ Zip Code: _____________

Phone #: _____________________ Email: _______________________________

All Veterans will need to submit their DD Form 214, Certificate of Release or Discharge from Active Duty, to be eligible. If you need assistance obtaining this form, contact our office at (630) 520-9450.

Please note that obtaining DD Form 214 can take up to 30 days, please contact our office as soon as possible so we can assist you.

If you have any questions, please contact our office: Mary Sheehy, Caseworker for Veterans Affairs Constituent.ServicesIL06@mail.house.gov (630) 520-9450

If you already have your DD Form 214, the deadline to submit the completed application and your DD Form 214 is March 23, 2020.

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Office of Congressman Sean Casten 2020 Application

Veteran or Applicant’s Signature

By signing in the space provided below, you are certifying that the information you have provided is true and accurate.

I, __________________________________, release this information to the Office of Congressman Sean Casten and his staff for the use in the Vietnam Veteran 50th Anniversary Commemoration Ceremony. I authorize Congressman Casten and his staff to release my name and photo in all promotional materials (website, e-newsletter, press release, social media).

I will attend this ceremony: • Yes, I will attend • No, I am unable to attend

If yes, how many people will be attending? ___________

Print Applicant Name: ________________________________________________

Applicant Signature: _________________________ Date: ______/______/______ (MM) (DD) (YY)

Please note that information submitted with your application cannot be returned. All information submitted with your application is subject to the Privacy Act of 1974, 5 U.S.C. Section 552(a), as amended and to the Freedom of Information Act, Section 552, as amended.

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