Last Name, First Name, MI:

Military Service: (A=Army, AF=Air Force, M=Marine  N=Navy  G=Coast Guard)

Service Indicator:             (Other Designation, please specify, eg, CIA/A)

Sex:          Marital Status (M=Married, S=Single):

             (If known, please provide any of the following.)

Date of Death/Incident (approximate is okay):

Date of Birth (Day-Month-Year):                           Rank:

Military Unit/Location:

Location of Incident, eg, Country/Province:

Home State and City:

Body Recovered (Y/N):                       [  ]  KIA    [  ]  Non-Hostile

Ever Designated POW/MIA (please specify):   [  ]  POW    [  ]  MIA

Panel location on the D.C. Vietnam War Memorial, "The Wall":

   Service or Serial No., eg, RA 11 618 891 (my own):

                           SSN (Social Security No.):

   CONFIDENTIALITY STATEMENT:  all service nos. and/or Social Security No.
   will be held confidential and any Casualty db distributed will not contain
   same.  The only use of such information with be to reconcile other sources
   of raw data to better provide accurate information.

   DISCLAIMER NOTICE:  THIS IS AN "UNOFFICIAL" EFFORT NOT ENDORSED BY NOR
   APPROVED BY ANY GOVERNMENT AGENCY.  THE ACCURACY OF THE DATA IS NOT
   GUARANTEED.  THEREFORE, THE USE OF THIS DATA IS AT YOUR OWN RISK AND
   IS PROVIDED "AS IS" WITHOUT ANY LIABILITY TO THE PUBLISHERS BEYOND
   WHAT IS ETHICALLY CONSIDERED A DUTY OF CONSCIENCE.