THIS PAGE MUST BE PRINTED AND MAILED:Please set ALL margins to .25"
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Veterans of the Vietnam War, Inc. Phone:
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805 South Township Blvd. (570) 603 - 9740 MEMBERSHIP
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Pittston, PA 18640-3327 APPLICATION
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__________________________________________________________________________________
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 MEMBERSHIP ELIGIBILITY:
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ALL VETERANS AND CONCERNED CITIZENS ARE WELCOME AND ENCOURAGED TO JOIN.
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PRINT
PRINT
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PERSONAL INFORMATION
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_______/_______/______
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NOTE: ENTER ALL DATES AS MONTH / DAY /YEAR
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SOCIAL SECURITY NUMBER
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____________________________ ______________________ ______
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LAST NAME FIRST NAME M. I.
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_________________________________ ___________
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STREET APT. NUMBER
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__________________________________ _________ ________-_______
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CITY STATE 9 DIGIT ZIP CODE
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(_______) _____________ ____/____/____ ______________ ______________
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AREA CODE PHONE NUM. DATE OF BIRTH MARITAL STATUS DEPENDENTS
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MILITARY INFORMATION (FROM DD-214) ATTACH COPY OF DD-214
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______________________________ _________________ SERVED IN VIETNAM (YEARS ONLY)
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BRANCH (AR NA AF MC CG RC) SERVICE NUMBER FIRST TOUR: FROM:______ TO:______
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___________________ ____/____/_____
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TYPE OF DISCHARGE DATE ENTERED SECOND TOUR: FROM:______TO:______
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_______________________ ____/____/_____
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SERVED IN VIETNAM (Y,N) DATE DISCHARGED THIRD TOUR: FROM:______TO:______
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________________
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MOS NUMBER FOURTH TOUR: FROM:______TO:______
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I hereby swear to uphold the Constitution DUES PAID:______________
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of the United States of America and the AMOUNT:_____$20.00_____
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By-Laws of The Veterans of the Vietnam War, Inc. RECEIVED BY:____________
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________________________________________ ____/____/____
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SIGNATURE DATE
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LIFE MEMBERSHIP - $200 ATTACH COPY OF DD-214
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PAYMENTS IN 8 MONTHLY $25 INCREMENTS
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'People Who Care'
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NON-PROFIT ORGANIZATION
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