Online Order Form

SECTION I - INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much as possible.)
1. NAME USED DURING SERVICE (last, first and middle)*
2. SOCIAL SECURITY NO.*
3. DATE OF BIRTH (MM/DD/YYYY)*
4. PLACE OF BIRTH
5. MILITARY SERVICE INFORMATION
  DATES OF SERVICE (Please Estimate) CHECK ONE
BRANCH OF SERVICE DATE ENTERED DATE RELEASED OFFICER ENLISTED SERVICE NUMBER
(Pre 1970 Only)
(if unknown, write “unknown”)
a. ACTIVE SERVICE
b. RESERVE SERVICE
c. ARMY/AIR
NATIONAL GUARD
7. HAVE YOU MADE A PRIOR REQUEST FOR YOUR RECORDS WITHIN THE PAST 90 DAYS?* Yes   No
SECTION II - INFORMATION AND/OR DOCUMENTS REQUESTED
DD FORM 214 OR EQUIVALENT
OTHER INFORMATION AND/OR DOCUMENTS REQUESTED

SECTION III - RETURN ADDRESS AND SIGNATURE
1. REQUESTER IS:
Military service member or veteran identified in Section I, above
Legal guardian (must submit copy of court appointment or power of attorney)


Please upload a copy of the Power of Attorney or Guardianship papers or fax them to (314) 442-4149
Next of kin of deceased veteran


Please upload a copy of the death certificate or obituary or fax a copy to (314) 442-4149
2 PURPOSE* (An explanation of the purpose of the request is required. Please be as specific as possible. If this request is for a funeral or burial please fax or email us either a copy of the death certificate, an obituary, or a note from the funeral home handling the arrangements on letterhead. Our fax and email address will be on the completed order form.)
Employment VA Loan Medical Education Benefits

3. SEND INFORMATION/DOCUMENTS TO:

Name* Phone Number*
Email Address* Street Address* Apt.
City* State* Zip Code*
Your Signature*
(?)
"Please sign the form by clicking on the signature line with
your mouse and moving the blue ball to create a written
signature. We cannot process your order without a signature."
SECTION IV- METHOD OF PAYMENT
 Express Service (USPS Regular Mail Shipping) $89.00
 Priority Express Service (Includes Emailed Copy & USPS Priority Mail Shipping) $114.00
Credit/Debit Card

Credit Card Information

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The CVV is a 3 digit code on the back of the VISA, MC, and Discover Card, and a 4 digit number on the front of the AMEX Card.

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