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Veterans of the Vietnam War, Inc. Phone:

805 South Township Blvd. (570) 603 - 9740 MEMBERSHIP

Pittston, PA 18640-3327 APPLICATION

__________________________________________________________________________________

MEMBERSHIP ELIGIBILITY:

ALL VETERANS AND CONCERNED CITIZENS ARE WELCOME AND ENCOURAGED TO JOIN.

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PERSONAL INFORMATION

_______/_______/______

NOTE: ENTER ALL DATES AS MONTH / DAY /YEAR

SOCIAL SECURITY NUMBER

____________________________ ______________________ ______

LAST NAME FIRST NAME M. I.

_________________________________ ___________

STREET APT. NUMBER

__________________________________ _________ ________-_______

CITY STATE 9 DIGIT ZIP CODE

(_______) _____________ ____/____/____ ______________ ______________

AREA CODE PHONE NUM. DATE OF BIRTH MARITAL STATUS DEPENDENTS

MILITARY INFORMATION (FROM DD-214) ATTACH COPY OF DD-214

______________________________ _________________ SERVED IN VIETNAM (YEARS ONLY)

BRANCH (AR NA AF MC CG RC) SERVICE NUMBER FIRST TOUR: FROM:______ TO:______

___________________ ____/____/_____

TYPE OF DISCHARGE DATE ENTERED SECOND TOUR: FROM:______TO:______

_______________________ ____/____/_____

SERVED IN VIETNAM (Y,N) DATE DISCHARGED THIRD TOUR: FROM:______TO:______

________________

MOS NUMBER FOURTH TOUR: FROM:______TO:______

I hereby swear to uphold the Constitution DUES PAID:______________

of the United States of America and the AMOUNT:_____$20.00_____

By-Laws of The Veterans of the Vietnam War, Inc. RECEIVED BY:____________

________________________________________ ____/____/____

SIGNATURE DATE

LIFE MEMBERSHIP - $200 ATTACH COPY OF DD-214

PAYMENTS IN 8 MONTHLY $25 INCREMENTS

'People Who Care'

NON-PROFIT ORGANIZATION

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