Chautauqua County Veterans Memorial Commission Database Enrollment Form

Please enter your information and submit the form below or you can click here to download and print the pdf enrollment form.

 

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Veteran Personal Information

First Name
M.I.
Last Name

Veteran Military Service

Date of Enlistment	mm/dd/yyyy
Branch	Army Air Force Navy Marine Corps Coast Guard
War	Peacetime Iraq Gulf Vietnam Korea WW2 WW1 Span-Am Civil Mexican 1812 Revolution
Unit
Rank	highest rank achieved
Places Served
Type of Duty  military occupation
Killed In Action (KIA)	Yes No
Prisoner Of War (POW)	Yes No
Missing In Action (MIA)	Yes No
Wounded In Action (WIA)	Yes No
Awards, Medals, Commendations
Other Information
Date of Discharge	mm/dd/yyyy
Town or City of Residence
Information Source	Name, relationship, phone number