Medal of Valor application

OMB No.: 1121-0259

Attachment A

Public Safety Officer Medal of Valor
Application for Extraordinary Valor
Above and Beyond the Call of Duty

* denotes required field.

Top of Form

About the Nominee

Salutation/Title

First Name*  

Middle Name

Last Name*  

Suffix

Social Security Number*  

 Sex*  

   (xxx-xx-xxxx)

Male

Female

Nominee's Contact Information
Home Address Line 1*
Home Address Line 2
City*	State*	ZIP Code*
E-mail Address*	Telephone Number (including area code)*
E-mail Address Confirmation*	Fax

About the Recommending Official
Salutation/Title*	First Name*	Middle Name		Last Name*	Suffix
Name of Appointing Authority/Submitting Agency*

Recommending Official's Contact Information
Agency Address Line 1*
Agency Address Line 2
City*		State*	ZIP Code*
E-mail Address*	Telephone Number (including area code)*
E-mail Address Confirmation*	Fax

Date of Event *   

(mm/dd/yyyy)

City/County/Township where event occurred *  

State where event occurred* 

Provide a brief summary of the act of valor for which the application is being offered. Please specify if the public safety officer is deceased. *   

	https://www.nationalmedalofvalor.org/medalofvalorform.aspx - #
	https://www.nationalmedalofvalor.org/medalofvalorform.aspx	https://www.nationalmedalofvalor.org/medalofvalorform.aspx - #

Bottom of Form

OJP Form 1673/1 (REV. 5-03)
Approved OMB 1121-0259
Expires 12/05

Public Safety Officer Medal of Valor
Application for Extraordinary Valor
Above and Beyond the Call of Duty

* denotes required field.

Top of Form

About the Nominee

Salutation/Title

First Name* *

Middle Name

Last Name* *

Suffix

Social Security Number* *

 Sex* *

   (xxx-xx-xxxx)

Male

Female

Nominee's Contact Information
Home Address Line 1* *
Home Address Line 2
City* *	State* *	ZIP Code* *
E-mail Address* *	Telephone Number (including area code)* *
E-mail Address Confirmation* *	Fax

About the Recommending Official
Salutation/Title* *	First Name* *	Middle Name		Last Name* *	Suffix
Name of Appointing Authority/Submitting Agency* *

Recommending Official's Contact Information
Agency Address Line 1* *
Agency Address Line 2
City* *		State* *	ZIP Code* *
E-mail Address* *	Telephone Number (including area code)* *
E-mail Address Confirmation* *	Fax

Date of Event *  *

(mm/dd/yyyy)

City/County/Township where event occurred * *

State where event occurred**

Provide a brief summary of the act of valor for which the application is being offered. Please specify if the public safety officer is deceased. *  *

	https://www.nationalmedalofvalor.org/medalofvalorform.aspx - #
	https://www.nationalmedalofvalor.org/medalofvalorform.aspx	https://www.nationalmedalofvalor.org/medalofvalorform.aspx - #

Bottom of Form

OJP Form 1673/1 (REV. 5-03)
Approved OMB 1121-0259
Expires 12/05