San Bernardino County
Recorder-County Clerk
222 W. Hospitality Lane, 1
st
Floor, San Bernardino CA 92415-0022
Hours 8 a.m. to 5:00 p.m., Monday-Friday
Phone: (855) REC-CLRK
www.sbcounty.gov/arc
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, Military Personnel Records at 1 Archives Drive, St. Louis, MO
63132-1002 or Fax (314) 801-9195 or visit the website at
www.archives.gov/st-louis.
INSTRUCTIONS: Please use a separate blank application for each request. All sections must be completed in their entirety.
•
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.
•
The County Recorder may provide a certified copy of a Military Service Record to an authorized person only, as described in
Government Code Section 6107(b).
CERTIFICATE INFORMATION – PLEASE PRINT LEGIBLY OR TYPE
Name on Military Discharge – First Name
Middle Name
Last Name
Date of Discharge: Branch of Service:
Date (Year) of Recording:
Number of Copies Requested
Sex: Male
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 Government Code Section 6107(b).
I am the person who is the subject of the record upon presentation of proper photo identification.
I am a f
amily member or legal representative of the person who is the subject of the record upon presentation of proper photo
identification and certification of their relationship to the subject of the record.
I represent a county office that provides veteran's benefits services upon written request of that office.
I am a United States official upon written request of that official. A public officer or employee is liable on his or her official bond
for failure or refusal to render the services.
I hereby certify that an official record copy with a full social security number is required in order to receive benefits per Government
Code Section 27303.5
I certify
(or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
BELOW SECTION FOR RECORDER’S USE ONLY
Document Number: Date of Recording: Number of Copies:
Date Processed:
(Circle One)
Counter Mail Fax
Type of I.D. and Identifying Numbers Clerk’s Initials
Rev. 08/30/17
