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Filipino American Heroes Memorial

Nomination Form

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1) Fil-Am Hero Last Name: _________________First:______________

2) Family/Org. sponsor: __________________  Prepared by: __________

3) Address: ____________________________________

4) City: _________________________  State: _____ Zip: ____________

5) Day Phone: ( __)______________  Home Phone: (___)____________

6) Fax or E‑mail: _____________________    Date of Birth:  __ /__ /___

  Enclosed is $100 check for FAMILY or ORGANIZATION membership, ID card AND a patriotic necktie OR a scarf OR a video/DVD “Fil-Am. Vets in Action.” $100 Check/Money Order/VISA numbers:______-______-_______ w/ expiration date:__/__/__ payable to:

          AM. COALITION for FILIPINO VETS.

                      841 South Glebe Road -  Arlington VA 22204

7)   LIFE member of ACFV?  (__) YES     Date of Death?  ____/ ___/ ___

8)   Medals?   Purple Heart (__) Bronze (__) WWII (__) other:__________

9)   Marital Status: (__)Single   (__)Married (__)Widow  

10) Spouse Name:________________ Age:____ Number of Children? ___

11) Have US service certification St. Louis, MO Army Records? (__)YES

12) Dates of service:__/___/__ HONORABLY discharged: ___/___/___  Serial No.:_____

13)   Category: Philippine Commonwealth Army(__)  Old Phil. Scouts(__)

      USAFFE Guerrilla(__)   New/Special Scout(__)  Unit?________

14) Have a VA Medical Identification Card (red-white & blue)? (__) YES

15) Applied for US VA COMPENSATION (__) benefit for WAR related

    injury or illnesses OR a VA PENSION? (__) YES  CLAIM No.________

16) Any war related injuries or illnesses?  ___________________

    Prisoner of war?: (__)YES  How long?_____ Bataan ___ Corregidor?___

17) VA compensation rating?  ____%  Dependent’s Indemnity? (__)YES

18) If deceased, did the nominee’s family receive U.S. burial benefits? (__)YES  (__)NO

19)  Why is the nominee heroic? Describe his/her sacrifices/exploits DURING the war? Tell us a short story. Please WRITE answers on separate sheet.

 20)  List nominee’s accomplishments before/AFTER the war. Describe the dreams when he/she arrived in US? A good parent? Three life lessons? Suggestions?

RELEASE of INFORMATION

We hereby release this information and 2 PHOTOS to the American Coalition for Filipino Veterans, Inc., a nonprofit membership organization, to honor the nominee in the Filipino American Heroes Memorial website and publication subject to ACFV approval.

Nominated  by: _____________________  Phone:___________ Date: __/__/__