Basket Factory Memorial Plaques

Basket Factory Memorial Plaques
Please give as much information as possible. At the bottom of the form is space of any other comments.
Known name (Select one). Each veteran deserves a separate record.*
Date of Birth

MonthDayYear
Date
Date of Death

MonthDayYear
Date
Date of Enlistment

MonthDayYear
Date
Branch
Address on Enlistment

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Unit(s) Regiment, Ship, Squadron
Where served
Rank on Release
Medals and Decorations
Parents’ Names
Job(s) at Basket Factory
Job(s) after return
Any address information would be appreciated.
Address(es) after return
Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date From 1
Date To 1
Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date From 2
Date To 2
Address 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date From 3
Date To 3
Address 4

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date From 4
Date To 4
Spouse(s)
Children
Volunteer activities
Pictures and/or other documents.

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Description of Pictures and documents if not apparent.
Other comments, including documents you may have.
Information is submitted by:
First Name*
Last Name*
Email*

Confirmation Emailexample@example.com
Day Phone Number
Format: (000) 000-0000.
Day Ext.
Night Phone Number
Format: (000) 000-0000.
Night Ext.
Should be Empty: