VETERANS OF THE VIETNAM WAR, INC.

                                               805 South Township Boulevard

                                           Pittston, Pennsylvania   18640-3327

                      Phone:  570-603-9740  Fax:  570-603-9741    1-800-VIETNAM

                             E-mail:  [email protected]   WebSite: www.vvnw.org

 

   "All Military All Veterans - Welcome"

 

MEMBERSHIP APPLICATION

 

GENERAL INFORMATION:

 

________-_____-________

         Social Security Number

       I hereby swear (affirm) to uphold the Constitution

     of the United States and the Bylaws of the

    Veterans of the Vietnam War, Inc.

       _______________________________

                                     Signature

 

PLEASE

      PRINT

 

 

____________________________________            ______________________________               _________

                            Last Name                                                                             First Name                                                      Middle

__________________________________________              _______         _______________________________

                                      Street                                                                  Apt. Number                                E-mail Address

__________________________________________                    __________                __________-________

                                       City                                                                                     State                                         Zip Code + 4

(           )  _________  -  ________________       _______________                                  

                   Telephone Number                            Date of Birth                         

 

MILITARY DATA:

Branch:

q       Army

q       Navy

q       Air Force

q       Marines

q       Coast Guard

q       Other ___________

 

Date

Entered Service  ______-______-____

 

Discharge Date  ______-______-____

 

Type Discharge     ___________________

 

Service Number    ___________________

 Service:

 

q       WW II

q       Korean

q       Vietnam

     

 

 

 

q       Gulf

q       Peacetime

q       Non-Veteran

q       All Others

TO CLAIM VETERAN STATUS YOU MUST ATTACH A COPY OF DD-214   (DISCHARGE FORM)

PAYMENT METHOD: 

 O Check or Money Order Payable to VVnW, Inc. enclosed   

 

Please charge my membership to:

   O Visa   O MasterCard   O Discover    O Am Express

 

Card No: _______________________ Exp Date________

 

Print  Name: ____________________________________

 

Signature : ______________________________________

 

                                   

                       We accept all major credit cards

 

q       Annual Membership  $20.00  

q       Life Membership  $200.00  

            ( 8 Payments of $ 25.00 )

      Current Serving Military FREE

 

 

 

OFFICE USE ONLY:

 

Post Number:      _______________

Dues Paid:            _______________   

Member Date:      _______________

Expiration Date:  _______________

Received  By:        _______________