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

Date Date Picker Icon

Date of Death

Date Date Picker Icon

Date of Enlistment

Date Date Picker Icon

Branch

Address on Enlistment

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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
City	State / Province
Postal / Zip Code	Country

Date From 1

Date To 1

Address 2

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date From 2

Date To 2

Address 3

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date From 3

Date To 3

Address 4

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date From 4

Date To 4

Spouse(s)

Children

Volunteer activities

Pictures and/or other documents.

Browse Files

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 Email example@example.com

Day Phone Number

Day Ext.

Night Phone Number

Night Ext.