AREAWIDE COMMUNITY SERVICES COUNCIL, CORP.
HC 35 Box 509, Wasilla, Alaska 99654

OFFICIAL APPLICATION - VETERANS' WALL OF HONOR

For nomination and acceptance to:
VETERANS' WALL OF HONOR AT BICENTENNIAL PARK
Mile Post 35.5, Parks Highway

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Print Name (1 letter in each block)
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Branch..............Rank....................Date of Service
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City (Birth/Home of Record/Place of Entry or Discharge)...State
TYPE OF DISCHARGE:__________________...SERVICE NO/SSAN:__________

REGISTRATION FEE: $50 PAYABLE TO: Veterans' Wall of Honor

MAIL TO: Areawide Community Services Council, Corp
............HC 35, Box 509..........................NUMBER_______
............Wasilla, Alaska 99654 ..............(Council Use Only)

COMMENTS:____________________________________________________________________

CERTIFICATION BY APPLICANT AND/OR SPONSOR
(Please read the following before signing)
I understand that if I willfully misrepresent or recklessly disregard any fact on this application, the above name will not be placed on the Veterans' Wall of Honor or may be removed if at a later date the information proves to be false. All money paid will be forfeited.

I, ___________________________________, hereby authorize the Areawide Community
(Signature)
Services Council Corp to verify the above information if so needed.

NAME:______________________________________ PHONE:___________________
ADDRESS:__________________________________ CITY:____________________ STATE:_______

Please complete this form and return with remittance. All above information is considered final. Changes in status will be published periodically in a roster listing American Veterans.

*** PLEASE NOTE: ANY AMERICAN VETERAN, LIVING OR DECEASED, WHO SERVED IN THE USA ARMED FORCES AND RECEIVED AN HONORABLE DISCHARGE, OR IS PRESENTLY IN THE MILITARY, IS ELIGIBLE TO HAVE HIS/HER NAME ON THE WALL OF HONOR.

THIS APPLICATION PRINTED FROM THE VETERANS WALL OF HONOR WEBPAGE