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DISABLED AMERICAN VETERANS CHAPTER 57 TAUNTON, MA.

Membership Application
Global War on Terrorism Memorial

Highlight the form Below, copy it then paste it into MS Works

DAV Chapter 57 Application

The cost of a life-long membership in the DAV is as follows and may be paid in interest-free installments over three years following a minimum $20.00 down payment:

DAV Life Membership is free to those over age 80

Age 71 - 79 ------------------------- $140.00

Cpl. Wm. F. Reardon, Ch.57, DAV

Age 61 - 70 ------------------------- $180.00

Membership Committee

Age 41 - 60 ------------------------- $230.00

P.O. Box 57

Age 40 - and under ------------- $250.00

Taunton, MA. 02780

____________________________________________________________________
Last Name, First Name Middle Initial:                           Male _____ Female ______
                                                                                                                                   
____________________________________________________________________
Spouses First Name:


____________________________________________________________________
Street Address:


____________________________________________________________________ 
City, State and Zip Code
Birth Date: __________________ Social Security Number: _________________

____________________________________________________________________
Date Enlisted:                           Date Discharged:            Branch of Service: Rank:

___________________________________
VA Claim Number

__________________________________     ______________________________
Signature:                                                                   Telephone Number:

_____________________________@____________________________________

Your E-mail Address

Amount Paid:
____________New life membership (Minimum $20.00 down) ____________ Life payment
Please list your chapter number and location (if known): _______MA. Chapter 57

I have a service-connected disability rated at ___________% (0% - 100%)

Disability Retirement from Military? -------------____ Yes ____No
Did you receive a Purple Heart? ------------------ ____ Yes ____ No
Are you an Ex-P.O.W.? ----------------------------- ____ Yes ____ No

__________________________________________ ___________________
Signature:                                                                               Date:

_______________________________________   ___________________
Sponsors Name and Code Number If Applicable:    Telephone Number:

____ Check or Money Order is enclosed.

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