2. Name of Veteran
4. Branch of Military
6. Name of Applicant
8. Relationship of Applicant to Veteran Being Honored
10. Applicant Address
12. Applicant Phone
14. Applicant Email Address
16. The fee for banner participation is $75.00
18. I hereby grant the Village of Midlothian permission to use the attached photo in their Hometown Heroes Banner Program with the understanding that this photo or likeness may be used for the Village's promotional use. I assume all responsibility for providing accurate, true and correct information regarding the Veteran being honored on the banner.
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20. 1. Receive an email copy of this form.
21. Email address

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22. Submit Submit and Print

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