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               Membership Application Form          Office Use

               Howard County Vietnam Veterans                  Date Accepted:________

              Organization, Inc.                                                Due Date:____________     

               8313E. 400S.                                                        Pd.ck#______________                

               Greentown, IN  46936                                        Pd.mo#_____________                 

                                                                                              cash_______________

              Phone: (765)628-0297  Fax: (75)628-3068                                            

               Email: vveterans@aol.com                                  

               Website: www.hcvvo.org

               Name:________________________________________  Date:_________

              Address:_____________________________________ City______________

              State:____  Zip:___________ Phone: (    )_______________

              Fax: (    )____________   Your email address:___________________

              Date of Birth:_______________

              Branch of Service:________________ Unit served with:______________

              # of years:_________________

    Check here if you prefer personal information remain confidential ________

           

             SERVED DURING (CHECK ALL THAT APPLY)

            ___ Vietnam (location served in country______________________________        

            ___Vietnam Era ___ Panama ___ WWII ___ Korea ___ Cold War ___ Peacetime

            ___Grenada ___ Gulf War ___Somalia ___ Bosnia ___ Lebanon ___ Kosovo

            ___ Afghanistan ___ Enduring Freedom ___ Operation Iraqi Freedom ___ Iraq

            ___ Assoc. non-veteran ___ Other (Please specify)______________________

            ***Please note that if you are a veteran, then you must supply a copy

         of your DD-214 with this appliation for membership***

        MEMBERSHIP TYPE: ___ single/annual ___single/lifetime ___new ___renewal

        As of January 2004, the fees are as follows: $20 single/annual and

         $100 single/lifetime

        Membership application taken by:__________________________        ______________________________________________________________________________

        FOR OFFICE USE ONLY

     Date Paid:_________________ Paid for with ___ cash

     ___ check (ck.#_________________)

     ___ money order (M.O.# ______________________)

     Paid by:_________________________   

    ____________________________________________________________________________