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2. Contact Name*
4. Address1*
6. City*
7. State
8. Zip
10. Phone Number*
12. Email*
14. Veteran Full Name *
16. Purple Heart / Bronze Star / Silver Star Recipient?
17. My Veteran is Proudly Honored by (i.e. The Smith Family)
19. Years/Era of Service
20. Eras of Service
    • World War I: April 6, 1917 - Nov. 11, 1918
    • World War II: Dec. 7, 1941 - Dec. 31, 1945
    • Cold War: Sept. 2, 1945 - Dec. 26, 1991
    • Korean Conflict: June 27, 1950 - Jan. 31, 1955
    • Vietnam Conflict: Feb. 28, 1962 - Nov. 7, 1975
    • Persian Gulf War: Aug. 2, 1990 - Aug. 31, 1991
    • Global War on Terror: Sept. 22, 2001 - Present
22. Plaque Inscription

    Please type in the space provide the information that you would like included on the plaque. (Max character limit of___).

24. How will you submit payment?*

    1. Online (Credit Card)
    2. Check

    Fee is $________. Online payment with a credit card is available on the Veterans Memorial Plaque website page. For checks, please make check out to Village of Homer Glen.

26. For all questions and inquiries:

    Please contact the Events Department at 708-301-0632 or email events@homerglenil.org.

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field