Membership is open to U.S. armed forces veterans who served on active duty (for other than training purposes) in the Republic of Vietnam between February 18, 1961 and May 7, 1975, or in any duty location between August 5, 1964 and May 7, 1975.

VIETNAM VETERANS OF AMERICA
APPLICATION FOR MEMBERSHIP
ATTENTION:  New annual members and new life members MUST submit a copy of your DD-214 form along with this application and your dues payment.

NAME:____________________________________

ADDRESS:____________________________________________ APT/SPACE:__________

CITY:____________________________STATE:__________________ZIP______________

HOME PHONE:_____________________WORK/OTHER PHONE:___________________

EMAIL ADDRESS:_______________________________DATE OF BIRTH:_____________

SEX:___________  CHAPTER # (IF KNOWN)_______________

SPONSOR:__________________________________

I AM ALREADY AN ANNUAL MEMBER AND WISH TO BECOME A LIFE MEMBER:

YES_____   NOT APPLICABLE:_______ IF YES, CURRENT MEMBER #_____________

TYPE OF MEMBERSHIP REQUESTED:

_____INDIVIDUAL MEMBER, 1 YEAR:   $20.00                         METHOD OF PAYMENT:
_____INDIVIDUAL MEMBER, 3 YEAR:   $50.00                         Cash____Check #______
_____LIFE MEMBER, CURRENT AGE:______   $________   Credit Card______

Credit Card Type:  Visa____  Master Card_____ Discover_____ American Express_____

Credit Card Number_____________________________ Exp. Date___________

Signature:_____________________________

LIFE MEMBER DUES CHART:
Ages 49 and under $250.00       Ages 50-55  $225.00       Ages 56-60  $200.00
Ages 61-65  $175.00                 Ages 66 and over  $150.00

Optional Payment Plan:  $50.00 down and $25.00 until total paid.

RETURN THIS COMPLETED FORM WITH YOUR COPY OF YOUR DD-214 AND YOUR CHECK OR MONEY ORDER TO:

Vietnam Veterans of America
P.O. Box 64299
Baltimore, MD  21264-4299