VVA Chapter 785 ~ 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 785

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

Richard Carroll

VVA-Director of Membership

26171 Erin Court
Lake Forest, California 92630

******************************************************

Office Use Only:

Membership Application Received: ___________   Application Forwarded to National: ___________