Requester Information Prefix First Name MI Last Name Address Line 1 Address Line 2 City State Alabama Alaska America Samoa Arizona Arkansas California Colorado Connecticut D.C. D.C. Delaware Federated States of Micronesia Florida Foreign Correspondence Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Email Phone More Information How Name Should Appear on Certificate Date to appear on certificate Years of Service Reason for Certificate Issue Special Honors/Civic Involvement Mail Certificate To Prefix First Name MI Last Name Address Line 1 Address Line 2 City State Alabama Alaska America Samoa Arizona Arkansas California Colorado Connecticut D.C. D.C. Delaware Federated States of Micronesia Florida Foreign Correspondence Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Email Phone