Application for Memorial Page

PORTRAITS OF FREEDOM ONLINE APPLICATION FORM PRIVATE AND CONFIDENTIAL Veterans for Constitutional Restoration (VCR), Inc. is a Nevada non-profit public benefit corporation. Payment for the Memorial Page can be by PayPal, check or money order. AFTER YOU HAVE SUBMITTED THIS FORM, PLEASE PRINT OUT THE CONFIRMATION PAGE, FILL IN ON IT THE NAME OF THE PERSON BEING HONORED AND MAIL WITH THE FEE TO: Veterans for Constitutional Restoration (VetsCoR) Inc. Portraits of Freedom 1976 Havasu Garden Drive, Lake Havasu City, AZ 86404 HARD COPY CONFIRMATION PAGE MUST BE SENT WITH YOUR PAYMENT IF PAYING BY CHECK OR MONEY ORDER. IF YOU USED PAYPAL TO MAKE PAYMENT FOR YOUR MEMORIAL PAGE, THE CONFIRMATION PAGE DOES NOT NEED TO BE MAILED IN. Those items marked with an * are required items: *Today's Date *Enter your Name: *Your E-Mail Address: Street Address City State zip code Telephone number *Name of person being recognized:  *Branch of Service *rank/rate/grade: *years of service (mm/yy): from: to: *Is the person being recognized: (check whichever applies): an honorably discharged or retired veteran? currently on Active Duty with the Military Forces of the United States? a Deceased Service Member who died on active duty? a Deceased Veteran? *Include your narrative/bio/tribute: Select what you want us to do now: Send information about VetsCoR I want to help VetsCoR in its mission! Have someone call Email me the URL of the page when completed. © 2004 Veterans for Constitutional Restoration, (VetsCoR) Inc.