Hall of Heroes

First Name *

Last Name (Current) *

Last Name (At Time of Graduation) *

High School Graduation Year *

Branch of Military *

First Year of Service *

Last Year of Service

Rank at Discharge or Current Rank *

Upload copy of any military report which would substantiate military service. For example: DD4, DD214, Declaration of service from commanding officer and others. Please eliminate any social security # information.

Upload your military portrait (.jpg, .gif, .bmp) Optional

Should the Patchogue-Medford Hall of Heroes team have further inquiry please provide your contact information below:

Phone Number *

Email Address *