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Veterans of the Vietnam War, Inc. Phone:
760 Jumper Road (717) 825- 7215 MEMBERSHIP
Wilkes-Barre, PA 18702-8033 APPLICATION
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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