____________________________________________________________________
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.
