New Page 1

VVA Logo

APPLICATION FOR MEMBERSHIP

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 28, 1961 and May 7, 1975, or in any duty location between August 5, 1964 and May 7, 1975.

ATTENTION: New members and new life members
You must submit a copy of your DD Form - 214 form
along with this application and dues payment.

Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

E-Mail Address:

Date of Birth:

Sex:

Optional:

Chapter No.

Sponsor:

___ I am already a VVA member and want to become a life member.
My VVA Member number is ______________ .

Type of Membership:

			Life Member-Ages 49 and Under : $250
	Individual Member -1 year: $20		Life Member-Ages 50-55: $225
	Individual Member- 3 years: $50		Life Member-Ages 56-60: $200
			Life Member-Ages 61-65: $175
			Life Member-Ages 66+: $150
			Optional Time Payment plan- $50 down, $25/month

Payment Method:

Check

Money Order

Credit Card (Visa, Mastercard, American Express, Discover)

Credit Card Number:

Exp. Date:

Signature:

Return your completed application, payment, and a copy of your DD Form-214 to:

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