AVVA Membership Application

This membership form may be completed and submitted online. Please mail your payment for the AVVA membership to:

Vietnam Veteran's of America
Chapter #20
P.O. Box 12580
Rochester, NY 14612

(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

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