Illinois Patriot Information Form - Illinois

The Illinois Secretary of State has released this version of the "Illinois Patriot Information Form" on October 1, 2018.

This form may be used by all Illinois residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Illinois Patriot Information Form
To all veterans and civilians who have served our country during times of war and of peace, please complete this form
and share your remembrances on the back or on a separate sheet of paper. As State Archivist and State Librarian, Secretary
of State Jesse White will ensure that these firsthand accounts will be commemorated, archived in Springfield and shared nationwide
and throughout the world. You will receive an official Certificate of Appreciation for your participation in this important Illinois
initiative. For information on recording an oral interview, please call 1-800-665-5576 ext. 6 or 217-785-1537 and ask
for the Veterans Project Coordinator.
Please print clearly.
Patriot’s name:_________________________________________ o
o
Veteran
Civilian
Birthplace:_________________________________________________ Birthdate: ___________________ Deceased: _________________
Length of Patriot’s Illinois residency: ________________________ o
o
Male
Female
Branch of service or wartime activity: ___________________________________________________________________________
Battalion, regiment, division, unit, ship, etc.: ______________ Highest rank: __________________________________________
o
o
o
Enlisted
Drafted
Academy
Service dates: __________________________________________
War(s) in which individual served: _________________________ Location(s) of military or civilian service: _________________
Was the veteran a Prisoner of War?______________________ Did the veteran sustain combat or service-related injuries?_____
Medals or special service awards: _______________________________________________________________________________
Name & address of individual submitting form: ________________________________________________________________________
City/State/ZIP: ____________________________________________ Phone: ______________________________________________________
Email:______________________________________________________ Relationship to Patriot being honored: _______________________
Is the Patriot interested in recording an oral history? o Yes o No
Release statement: (I understand I do not give up any copyright I may hold.)
By submitting this form, I give the Veterans’ History Project of the Illinois State Archives the right to permanently:
• Hold this material in the Illinois State Archives collections;
• Use this material for research, scholarly and educational purposes;
• Permit the use of this material by any office or agency of Illinois state government for exhibition, publication and presentation;
• Have the document placed in the Illinois Digital Archives (www.idaillinois.org).
Please return this form to:
Secretary of State Jesse White • Illinois Veterans’ History Project
Illinois State Library • 300 S. Second St., Room 410 • Springfield, IL 62701
To participate in the National Veterans’ Oral History Project at the Library of Congress, contact:
Veterans’ History Project • American Folklife Center • Library of Congress
101 Independence Ave., SE • Washington, D.C. 20540-4615 • www.loc.gov/vets/
Patriotic Partners
Printed by authority of the State of Illinois. October 2018 — 10.5M — AR D 138.10
Print
Reset
Illinois Patriot Information Form
To all veterans and civilians who have served our country during times of war and of peace, please complete this form
and share your remembrances on the back or on a separate sheet of paper. As State Archivist and State Librarian, Secretary
of State Jesse White will ensure that these firsthand accounts will be commemorated, archived in Springfield and shared nationwide
and throughout the world. You will receive an official Certificate of Appreciation for your participation in this important Illinois
initiative. For information on recording an oral interview, please call 1-800-665-5576 ext. 6 or 217-785-1537 and ask
for the Veterans Project Coordinator.
Please print clearly.
Patriot’s name:_________________________________________ o
o
Veteran
Civilian
Birthplace:_________________________________________________ Birthdate: ___________________ Deceased: _________________
Length of Patriot’s Illinois residency: ________________________ o
o
Male
Female
Branch of service or wartime activity: ___________________________________________________________________________
Battalion, regiment, division, unit, ship, etc.: ______________ Highest rank: __________________________________________
o
o
o
Enlisted
Drafted
Academy
Service dates: __________________________________________
War(s) in which individual served: _________________________ Location(s) of military or civilian service: _________________
Was the veteran a Prisoner of War?______________________ Did the veteran sustain combat or service-related injuries?_____
Medals or special service awards: _______________________________________________________________________________
Name & address of individual submitting form: ________________________________________________________________________
City/State/ZIP: ____________________________________________ Phone: ______________________________________________________
Email:______________________________________________________ Relationship to Patriot being honored: _______________________
Is the Patriot interested in recording an oral history? o Yes o No
Release statement: (I understand I do not give up any copyright I may hold.)
By submitting this form, I give the Veterans’ History Project of the Illinois State Archives the right to permanently:
• Hold this material in the Illinois State Archives collections;
• Use this material for research, scholarly and educational purposes;
• Permit the use of this material by any office or agency of Illinois state government for exhibition, publication and presentation;
• Have the document placed in the Illinois Digital Archives (www.idaillinois.org).
Please return this form to:
Secretary of State Jesse White • Illinois Veterans’ History Project
Illinois State Library • 300 S. Second St., Room 410 • Springfield, IL 62701
To participate in the National Veterans’ Oral History Project at the Library of Congress, contact:
Veterans’ History Project • American Folklife Center • Library of Congress
101 Independence Ave., SE • Washington, D.C. 20540-4615 • www.loc.gov/vets/
Patriotic Partners
Printed by authority of the State of Illinois. October 2018 — 10.5M — AR D 138.10

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