Full Name:__________________________________________________________
Sponsor ( Leave blank if none )________________________

Home/Mailing Address:________________________________________________

City:__________________________ State:___________________ Zip: _________

Home Phone:__________________  Date of Birth:___________________________

Age: _________________________  Social Security Number__________________

Occupation:_________________________________________________________

United States Military Veteran?________ Branch of Service:____________________

Service date from:_____________________ to _____________________________

DD 214 required _______________   SF 180 ( we WILL file for service verification )

Married?______________________ If so, your spouses name:_________________

Our member dues are $ 15.00 per year and associate dues are $ 10.00 per year

Your Signature:______________________________________________________

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To become a Member in the Vietnam Veterans of America, you must have served in a branch of the armed
forces of the United States of America between the dates of January 1, 1959 - May 7, 1975 and have been
discharged under Honorable Conditions or be currently active in a branch of the military and served during
the above dates.
To become an Associate Member in the Vietnam Veterans of America, you must have a genuine interest in
our aims and goals.   Anyone can become an Associate Member.
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Print this page and mail to our Chapter or email the above information to us and we'll
contact you ASAP.
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