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VVA Chapter 975
~ Membership Application
PERSONAL INFORMATION
Name:_______________________________________________________________
Address: ________________________________ City: ________________
State: _____ Zip Code: _________
Telephone Numbers-
Home: ( ) _____ - _______
Work: ( ) _____ - _______
Cell: ( ) _____ - _______
E-Mail: ________________________________________
Date of Birth: _________
Gender: M F (Circle One)
TYPE OF MEMBERSHIP- Select One
Yearly Memberships ___ :
Individual Member -1 year: $20 ___ :
Individual Member- 3 years: $50
Life Memberships ___:
Life Member- Ages 49 and Under : $250 ___:
Life Member- Ages 50-55: $225 ___:
Life Member- Ages 56-60: $200 ___:
Life Member- Ages 61-65: $175 ___:
Life Member- Ages 66+: $150 ___:
Optional Time Payment plan
(Life Membership)- $50 down, $25/month (also select an age category)
PAYMENT METHOD
Payment can be in the form of check or money order payable to:
VVA 975 Return your completed application, payment, WITH a copy of your
DD Form-214 to:
Ralph McKie
President Mohave County Chapter 975
P.O. Box 184
Kingman, Arizona 86402
******************************************************
Office Use Only:
Membership Application
Received: ___________ Application
Forwarded to National: ___________
Down load application Here:
for word
for PDF
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