| Your Personal Information |
| Your Name: |
| Your Street: |
| Your City, State & Zip: |
| Your Email: |
| Your Phone: |
| How do you want to be contacted?: |
| Signature/Authorization: |
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| Your Service Information |
| Country of Service: |
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| Agency/Branch of Service: |
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| Highest Rank: |
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| No of SE Asia Tours/Assignments: |
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| Total Years of Your Service: |
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| Discharge Date (MM/DD/YYYY): |
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| Discharge Type: |
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| Tour/Dates & US MOS/Rating/NEOC (Job Identifiers): |
| Type |
Tour 1 |
Tour 2 |
Tour 3 |
Tour 4 |
Tour 5 |
| Highest Rank |
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| Start Date |
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| End Date |
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| Advisory Title |
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| Primary |
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| Secondary |
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| Your Military Combat Honors & Citations: |
| Check |
Abbrv |
Name |
| US Medals Awarded to You |
| POW | Prisoner of War Medal |
| CBR | Combat Inf Badge, Combat Act Ribbon |
| PHM | Purple Heart Medal |
| BSM | Bronze Star Medal |
| ISM | Soldier's, Airman's, Navy & Marine Corps Medal |
| DFC | Distinguished Flying Cross |
| LMM | Legion of Merit Medal |
| SSM | Silver Star Medal |
| DSM | Army, Navy, Coast Guard Dist Svc Medal |
| DSC | Army Dist Svc Cross, Navy Cross, Air Force Cross,
Coast Guard Cross |
| MOH | Medal of Honor |
| AUS, KOR, PHL, ESP, NZL, THA, TWN Medals & Citations Awarded to You |
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| Your Southeast Asia Tour(s) of Duty |
| Advisory HQ Information |
| Tour |
Corps |
Prov/CAG |
City/Town |
Team No |
PSA/CAG Co Name |
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| 2 |
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| 3 |
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| 4 |
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| 5 |
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| Advisory Team Unit Information |
| Tour |
Dist/CACO |
DSA/CACO Ldr Name |
Team No |
Town/Village |
Sub/Mobile Tm |
Mobile Tm Ldr |
| 1 |
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| 2 |
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| 3 |
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| Advised Foreign Unit Information |
| Tour No |
Div Name |
Div No |
Bgd No |
Bn No |
Co/CAG |
Base Name |
Base Loc |
| 1 |
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| 2 |
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| 3 |
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| 4 |
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| 5 |
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| Non-Advisory US & Other
Foreign Unit(s) Information |
| Tour No |
Div Name |
Div No |
Bgd No |
Bn No |
Co ID |
Base Name |
Base Loc |
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| 2 |
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| 3 |
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| 4 |
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| 5 |
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| Indicate Those Members & Counterparts You Would Like to Locate |
| Tour |
Locate |
List Advisory Team Members
( Include Rank, Full Name, Home of Record ) |
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| Tour |
Locate |
List Your Counterparts Info
( List Rank, Title, Full Name, Family Home, etc. ) |
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