Relation_A
—Please choose an option—2nd Great Grandfather2nd Great Uncle3rd Great Grandfather3rd Great Uncle4th Great Grandfather4th Great Uncle5th Great Grandfather5th Great Uncle6th Great Grandfather6th Great Uncle7th Great Grandfather7th Great Uncle8th Great GrandfatherCousinFatherGrandfatherGreat GrandfatherGreat UncleUncle

NameConfederateSoldier

SoldierLocation_City

SoldierLocation_State
—Please choose an option—AKALARAZCACOCTDCDEFLGAIAIDILINKSKYLAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY

SoldierLineal
SoldierLineal

SoldierCollateral
SoldierCollateral

SoldierRank
—Please choose an option—1st Corporal1st Lt.1st Sergeant2nd Corporal2nd Lt.2nd Sergeant3rd SergeantAsst SurgeonBody ServantBrigadier GeneralCaptainChaplainColonelCorporalGeneralLt. ColonelLt. GeneralMajorMajor GeneralPrivateScoutSergeantSgt MajorSurgeon

SoldierCompany
—Please choose an option—ABCDEFGHIJKLMNOP

SoldierRegiment

SoldierParoled-CheckBox
SoldierParoled-CheckBox

SoldierSurrendered-CheckBox
SoldierSurrendered-CheckBox

SoldierReleasedOnOath-CheckBox
SoldierReleasedOnOath-CheckBox

SoldierDischarged-CheckBox
SoldierDischarged-CheckBox

SoldierKilled-CheckBox
SoldierKilled-CheckBox

SoldierDied-CheckBox
SoldierDied-CheckBox

SoldierDeathDate

SoldierBurialSite

ApplicantFullName

ApplicantSignature

ApplicantAddress

ApplicantCity

ApplicantState
—Please choose an option—AKALARASAZCACOCTDCDEFLFMGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPRPWRISCSDTNTXUTVAVIVTWAWIWVWY

ApplicantZipCode

ApplicantDOB

ApplicantOccupation

ApplicantMobilePhone

ApplicantOtherPhone

ApplicantEmailAddress

ApplicantRefferedBy

RefferersCampNameNumber

CampCommitteeSig2

CampCommitteSig1

CommitteeSig1SCVID

CommitteeSig2SCVID

DateofApplication

DateReceivedField