ABOVE & BEYOND MEMORIAL SPONSORSHIP FORM DONOR INFORMATION Name:______________________________________________ Address:____________________________________________ City:_____________________ State:____ Zip:_________ - _______ COST $25 EACH Method of Payment:  ______ Check ______ Visa ______ MasterCard Card Number:_____________________________ Expiration Date:_____ / _____ Signature:__________________________________ DOG TAG IMPRINT INFORMATION (Casualty Information) (If you do not have a specific name to sponsor, please check the following and leave the rest blank) ______ I would like to sponsor a tag, please pick a veteran's name for me. Full Name: _____________________________________________________ Branch of Service (pick one): ______ USA ______ USAF ______ USMC ______ USN ______ USCG Date of Casualty: ___________________________ ______ I would like to receive a duplicate tag as a personal memento at no extra charge. Please print out and mail to: National Vietnam Veterans Art Museum 1801 S. Indiana Avenue Chicago, IL 60616 Or Fax to: 312-326-9767 For further information please contact the Museum at 312-326-0270 during the hours. Thank you for your support of the Above and Beyond Memorial Sculpture.