Board of Directors
Stephen “Lance” Cole
Rey Cordero
Charlie (PJ) Coulter
Karen Kish
James D. Moore
Ted Mosure
Terri Swank

Ohio Military Hall of Fame for Valor
5195 Hampsted Village Center Way
Personal Mailbox 182
New Albany, OH 43054-8331

Honorary Board Members
Jody WhiteMG Deborah Ashenhurst, U.S. Army, Ret.
Director, Ohio Dept. of Veterans Services
Directors Emerita/Emeritus
Beth Eckersley
James Garvey

Date of Application: _______________________
Last Name: __________________________ First Name: ___________________ MI: __Street Number and Name: __________________________________________________
City: ________________________________ State: _________ Zip Code ____________
Email Address: ___________________________________
Service Number: ______________________ Branch of Service: ___________________
Place of Birth: ____________________ Entered Service From: ____________________
Dates of Active-Duty Service: _______________________________________________
Veteran was awarded the following medal for a specific act of VALOR:
Medal of Honor ____
Distinguished Service Cross ______ Navy Cross ______ Air Force Cross_______
Silver Star _____
Distinguished Flying Cross for HEROISM _____ (Subject to Citation Review)
Bronze Star with “V” Device _____ (Subject to Citation Review to verify
Heroism/Valor)
Air Medal with “V” Device ______ (Subject to Citation Review to verify
Heroism/Valor)
Commendation Medal with “V” Device _______ (Subject to Review to verify
Heroism/Valor)
Achievement Medal with “V” Device _______ (Subject or Review to verify
Heroism/Valor)
The above award was made for action in (War/Conflict)__________________________
Date of action on citation: ___________________________________________________________All Gave Some, Some Gave All
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Ohio Military Hall of Fame for Valor
Application for Acceptance
Page 2 OF 2

THE OHIO MILITARY HALL OF FAME
Attached please find the following Exhibits for verification of the award
listed on page 1.
Form DD-214 or Equivalent (REQUIRED FOR ACCEPTANCE) ______
Copy of Medal Certificate and Citation accompanying the award______

Copy of the General Order for the Award, if available.

______

Other (Please Specify) __________________________________ ______
Please provide the name of your State Legislators if you know who they are.
If not, we can research based on point-of-contact address. Reason: werequest a personal commendation for you from each of them, as well asother elected officials:
Ohio Senator: _________________________________________
Ohio Representative: _____________________________________
AFFIDAVIT AND AUTHORIZATIONThe undersigned hereby acknowledges that the submission of false documentation for anaward may be punishable by law. The undersigned hereby authorizes any member of
The Board of Directors of The Ohio Military Hall of Fame to authenticate my individual
personnel records from Military Records Sources and conduct a background check, if
deemed necessary by the Board of Directors. The undersigned agrees to have contact
information released to the media in connection with the induction ceremony, incompliance with our long-standing policy.

__________________________________________________

Signature

Date__________________________________________________

Primary Phone Number with Area Code

Secondary Phone NumberAll Gave Some, Some Gave All
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