San Bernardino County Recorder Larry Walker, Auditor/Controller-Recorder 222 W. Hospitality Lane, 1st Floor, San Bernardino CA 92415-0022 Hours 8 a.m. to 4:30 p.m., Monday-Friday Phone: (909) 386-8947 or Fax (909) 386-8700 www.sbcounty.gov/acr APPLICATION FOR MILITARY SERVICE RECORD INFORMATION: The San Bernardino County Recorder’s Office only has records of Military Service that have been recorded in San Bernardino County. Please contact the specific County where the Military Service Record has been recorded to obtain copies. Copies can also be requested by writing to the National Personnel Records Center at 9700 Page Avenue, St. Louis, MO 63132-5100 or Fax (314) 801-9195 or visit the website of http://members.aol.com/forvets/htomr.htm. INSTRUCTIONS: Please use a separate blank application for each request. All sections must be completed in their entirety. CERTIFICATE INFORMATION – PLEASE PRINT LEGIBLY OR TYPE 1. Give all the information you have available for the identification of the record. If the information you furnish is incomplete or inaccurate, it may be impossible to locate the record. 2. The County Recorder may provide a certified copy of a Military Service Record to an authorized person only, as described in Health and Safety Code Section 103526. Name on Military Discharge – First Name Date of Discharge: Middle Name Last Name Date (Year) of Recording: Branch of Service: Sex: Male ‫ڤ‬ Number of Copies Requested Female ‫ڤ‬ APPLICANT INFORMATION – PLEASE PRINT LEGIBLY OR TYPE 1. Appearing In Person – San Bernardino County requires photo identification. Applicants will need to sign the application in front of a member of our staff. 2. Mail Requests – Complete this bottom section but do not sign the Penalty of Perjury statement. See the reverse side of form. Purpose for Which Military Record is to Be Used Relationship to Subject of Record Name of Person Completing Application Daytime Telephone Number – Area Code First Address – Number, Street, and Unit # (if applicable) City State Zip Code I agree not to use the Military Discharge obtained from this application or any portion thereof, for fraudulent purposes. I am signing my own legal name and I am an authorized person as shown in Health and Safety Code Section 103526. I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Signature BELOW SECTION FOR RECORDER’S USE ONLY Document Number: Date Processed: Rev. 01/01/08 Date of Recording: Counter (Circle One) Mail Fax Type of I.D. and Identifying Numbers Number of Copies: Clerk’s Initials American LegalNet, Inc. www.FormsWorkflow.com IMPORTANT Authorized Persons/Regular Certified Copies – Requestor will need to sign this penalty of perjury statement in front of a notary public prior to submission. Please Note: When submitting multiple certificate requests, all must be signed however, only one request would require the notarized statement. I agree not to use the record obtained from this application or any portion thereof, for fraudulent purposes. I am signing my own legal name and I am an authorized person as shown in Health and Safety Code Section 103526. I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature CERTIFICATE OF ACKNOWLEDGMENT State of } ss. County of ______________ On before me, ____________________________________, (Name and title) personally appeared , proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. _____________________________________ (NOTARY SEAL) NOTARY SIGNATURE Notary name: County of Principle Place of Business: Telephone Number: Registration Number: Commission Expiration Date: American LegalNet, Inc. www.FormsWorkflow.com