On Line Membership Application
VIETNAM VETERANS,
INC.
P. O. Box 684
LaPorte, Indiana 46352
(219) 326-0523
www.namvets.com
The purpose of this application is to insure credibility. To acquire membership, this application must be filled out in full. The Membership Committee’s assignment is to review eligibility. In order to obtain membership a copy of the applicant’s DD 214 is requested. Any false information provided will constitute denial of membership.
Name: __________________________________________________ Date of Birth:_____________________________
Address: _________________________________________________ Phone: ( )_____________________________
_________________________________________________ Cell Phone: ( _)_________________________
_________________________________________________ Email: __________________________________
Marital Status:
Single Married Divorced Separated If married, spouse’s name: _______________________________________Children: ____________________________________________________________________________________________________
Employment: ____________________________________________________ Occupation: __________________________________
Hobbies & Interests: ___________________________________________________________________________________________
Branch of Service: ________________________________________________ Military Occupation: ___________________________
Military Service Number: ___________________________________________ Reserve Status: ______________________________
Type of Discharge: _______________________________________________ Percent of Disability (if any): _____________________
Military Service: (From) _________________________________________ (To) ___________________________________________
Vietnam Service: (From) ________________________________________ (To) ___________________________________________
Geographical Area of Vietnam Service: ____________________________________________________________________________
Unit(s) Served With: ___________________________________________________________Rank: ___________________________
I, the Applicant, do hereby swear that all information submitted on this application is true and correct to the very best of knowledge.
Signature: __________________________________________________________ Date: ___________________________________
Note
: We are proud Americans and will not have any working relationships or affiliation with the Communist Party or any other organization, agency, cause, etc. that advocates the overthrow of the United States government. Each member is equally important and has as much to offer in his own way as his fellow members. What is most important is our Mission; therefore, we place principles above personalities. To what extent each member becomes involved in activities and events is strictly up to that member and will not be questioned.
ANNUAL DUES ARE $12.00