By signing (typing your legal name) in the space below, you are certifying:
I release this information to the Office of Congressman Ed Perlmutter for the use in the Vietnam War 50th Commemoration. I authorize Congressman Perlmutter to release my name and photo in all promotional materials (website, e-newsletter, press release, ect.)
I am a legal resident of the State of Colorado.
If I have not submitted ALL required documents, I will not be eligible to receive a Lapel Pin
When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.