INSTRUCTIONS: Fill in appropriate sections on this page. Submit one form for each
soldier you Honor. Please type, or handprint all information with  black ink. Do not
use a "highlighter" on any documents. A special Certificate with the Honored soldier’s 
name will be forwarded to you. The Ascent and Documentation form is not required, 
but is welcome if you want to include a few certificates or documents with this application.

I wish to honor the memory of a soldier and/or support the Gustave Koerner House
Preservation Project and hereby ___ Honor-a-Soldier (no documentation necessary). 
Enclosed is my $35.00 application fee. 

____I would also like the society to procure this soldier’s Military Service record 
or Pension Documents Packet from the National Archives in Washington, D.C., to be 
preserved with this application as outlined in Disposition of Documents. 
Enclosed is an additional $17.00 to cover the cost of photocopies of these files [a fee 
increase is pending 6/2007 for these documents].


Applicant’s Name as it is to be shown on the Certificate
	___________________________________________________________________________
	                                                     
Spouse 	___________________________ (optional)
Address	___________________________________________________________________
City    	_______________________	State _________	9-digit Zip __________–________

I agree that this application and all documents tendered with it become the property of the 
St. Clair County Historical Society and may be stored, preserved, and published as outlined 
in the paragraph titled Disposition of Applications and Documentation.
Date: ___________________	Signature: _________________________________________


Please send membership information on the Historical Society     _______
Click this link for information on the Genealogical Society 

Society Use Only

Date Received_________	Amount Paid (No cash)__________	

Certificate No. Issued  _________    Date_________	Certificate Mailed Date __________


MAIL this application, your check or money order for $35.00** (or $52.00 if you wish the society
to procure service or pension papers) to: SCCHS–Koerner Fund, 701 East Washington Street,
Belleville, IL 62220. **$25.00 will be donated to the Gustave Koerner House Preservation.