Member Application

For new members, this membership form may be completed and printed online and mailed with your payment and a copy of the DD214 form. Renewal members may complete and print the form and mail it with your payment. Vietnam Veteran's of America, Chapter #20, P.O. Box 12580, Rochester, NY 14612.

Membership Application

(bold fields are required.)

First Name

Last Name

Address

City, State, Zip Code

Home Phone, Ext.

Phone: (NNN) NNN-NNNN Ext: NNNN

Work Phone, Ext.

Phone: (NNN) NNN-NNNN Ext: NNNN

Primary Email

Date of Birth

Date: MM/DD/YYYY

Term

Annual Membership: 1 year $20.00

3-Year Membership: $50.00

Lifetime Membership:
             $250.00/ 49 years of age and under
             $225.00/ 50 years - 55 years of age
             $200.00/ 56 years - 60 years of age
             $175.00/ 61 years - 65 years of age
             $150.00/ 66 years of age