National Purple Heart Hall of Honor Enrollment Form

Enrollment Submission Date (Today):*

MonthDayYear
Date
RECIPIENT INFORMATION:
Prefix Dr., Mr., Mrs. Ms:*
Name (First, Middle, Last, Suffix):*
Current Address (If living):*
City:*
State:*
Zip:*
Hometown Town (at time of service)
City:*
State:*
Date of Birth:*

MonthDayYear
Date
Date of Death (If applicable):

MonthDayYear
Date
Please affirm:

Yes, I understand I must submit proper verification of receipt of the Purple Heart for enrollment in the Roll of Honor
Please include a copy of one or more of the following:*

DD-214 or DD-215 (Discharge Papers)WD-AGO 53-55 (WWII Discharge Papers)General or Permanent Orders listing the awardPurple Heart Award Certificate
Upload your verification document here:

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If you do not have any of these items, please call the National Purple Heart Hall of Honor at 845-561-1765 for further information and clarification.

The Roll of Honor database is intended to commemorate the sacrifices of Purple Heart recipients by gathering and sharing their stories. Enrollments are voluntary and National Purple Heart Hall of Honor staff make a good faith effort to review and verify the accuracy of all official documents submitted. The National Purple Heart Honor Mission and the National Purple Heart Hall of Honor are not affiliated with the Department of Defense, the military branches of service, or any other organizations. The Hall of Honor reserves the right to verify relevant documents through the National Personnel Records Center and/or Branch of Service awards command.
CONTACT INFORMATION:
Contact Name:*
Your relationship the to recipient:*
Phone:*
example: 1-555-555-5555
Email:
example@example.com
Address:*
City:*
State:
Zip:*
Would you like to receive NPHHH information or mailings in the future?

YesNo
OTHER INFORMATION:
Photos can be uploaded here or mailed to P.O. Box 207, Vails Gate, NY 12584. Photos cannot be larger than 8” x10” and the Hall of Honor cannot return photos as they become part of the archive.

I am uploading a photoI am mailing a photo
Please identify the source of the photographs you are submitting:

PersonalOther
Upload photo here

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Share a short (paragraph length) narrative that describes how you (or the recipient) were wounded
We will accept up to five pages of additional material (photos/letters/documents) that can be scanned to become part of the Roll of Honor.

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DATES OF SERVICE:
Entered:*

MonthDayYear
Date
Discharged:*

MonthDayYear
Date
STATUS (check one)

WIAKIAPOWMIADied of Wounds
Date when wounded or killed:

MonthDayYear
Date
Rank when wounded or killed:
Conflict/War during which recipient was wounded or killed:*
And one or more of the following (if known):
Campaign in which recipient was wounded:
Battle in which recipient was wounded:
Geographical Location where recipient was wounded:
(If more than one Purple Heart has been awarded, please attach additional enrollment form to detail circumstances.)
BRANCH OF SERVICE & UNIT INFORMATION:
Army (Unit):
Air Force (Unit) :
Coast Guard (Unit):
Marines (Unit):
Navy (Unit/Ship):
Merchant Marine (Ship):
Army Air Force* (Unit) :
*WWII ONLY
How did you learn about the National Purple Heart Hall of Honor?

National Purple Heart Honor MissionNewspaperRadioFriendOther
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OTHER INFORMATION:

BRANCH OF SERVICE & UNIT INFORMATION: