AVVA MEMBERSHIP APPLICATION

 

Member Status (circle one) 1yr. / 3yr. / Life (refer to chart below)*

 

Name:________________________________________________

 

Address:______________________________________________

City:__________________ State:____________ Zip:__________

E-Mail: (optional)_______________________________________

DOB:____/____/____     Age:________        ____Male ____Female

 

 

Phone: (h) (_____)_____________ (w) (_____)_______________

 

 

Payment Method (circle one):    Check           Money Order 

 

*One Year @ $20.00______________ Three Years @ $50.00_______________

 

Life member (select payment from table below):

 

Age 49 and Under $250.00___________

Age 50 to 55        $225.00___________

Age 56 to 60        $200.00___________

Age 61 to 65        $175.00___________

Age 66 and over   $150.00___________

 

 

MAIL TO:

Vietnam Veterans of America, Inc.

Bucktail Chapter 720

AVVA (ATTN: Membership)

P.O. Box 220

St. Marys, Pa. 15857