Please complete the following application and return with necessary documents to 
Stanley Schmucker
Administrative and Financial Officer, NOBC
1490 Independence Ave. 
Melbourne, FL 32940

GENERAL INFORMATION Please print or type all information.
 
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Full name: First                    Middle                                  Last 

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Address:                                                           Phone Number: 

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City:                           State:                                   Zip: 

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Date of Birth:                   Place of Birth:               SS#: (Last four digits only.) 

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Name of Wife or Next of Kin: 

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Address if Different: 

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Number of Children: 

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Membership in Other Veteran Organizations: 

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How did you learn about NOBC? 

MILITARY INFORMATION 

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Date of Entry:                   Service:                                  Branch:

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Unit Assignment and Position at Time of Commission:

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Date of Commission:                                        Location:

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Issuing Headquarters:      

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Years of Service:                         Highest Rank: (  Active,  Reserve,  NG)

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Personal Decorations and Awards:

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Campaigns:

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Other Information: (If additional space is needed, attach comments on plain paper)

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Certificate:
I certify that to the best of my knowledge the information submitted is accurate and true.  
Further, that having proved my courage and leadership on the field of battle in the 
defense of the United States of America, I pledge to promote the enhancement of these 
characteristics in future generations of Americans.  I further certify that the execution 
of this form is voluntary.

Please sign here:_____________________________________ Date: ___________________________________

The information on this form is for sole use of the organization.  Names, postal addresses 
and telephone numbers will not be shared in any way, with any other entity.

(Revised 12/05/06)