Gold Star Honor Roll Form

To submit a veteran to be considered for the Gold Star Honor Roll, please provide us with the following information about the service member:

*First Name:

Middle Name:

*Last Name:

Branch:

Rank (e.g. private, lieutenant, etc.):

Company:

Unit:

City:

County:

State:

Date of Birth (mm/dd/yyyy):

*Casualty Date (year):

Location of casualty:

Were they in active duty at time of death?

Yes

*Name of War or Conflict:

Expected year of graduation from UW-Madison:

Description or details you would like to share:

Attach an image (file size less than 500Kb)

*Your (submitter’s) name:

*Your (submitter’s) email address:

Your (submitter’s) phone number: