117th ASSAULT HELICOPTER COMPANY VIETNAM ASSOCIATION

MEMBERSHIP APPLICATION

(PLEASE PRINT)


PLEASE PLACE A CHECK MARK OR AN ‘X’ ON THE LINE TO INDICATE THE TYPE OF MEMBERSHIP YOU ARE APPLYING FOR.

___ LIFE MEMBERSHIP - $150.00 (VETERANS ONLY) ___ REGULAR MEMBERSHIP - $15.00 PER YEAR (VETERANS ONLY)

(FIRST) (MIDDLE) (LAST)

If veteran is deceased, your relationship to the veteran?__________________________________________________


If veteran is deceased, what was the date and cause of veterans death?_____________________________________


Mailing Address:________________________________________________________________________

City:____________________________________State:________________________Zip:________

E-Mail:_______________________________________________

Telephone:(_________)___________________________


FOR VETERAN USE ONLY


Date of Birth:_______________________________

Spouse’s Name:___________________________________________


Service Number:_______________/_________________/_____________________


Your Current Occupation?________________________________________________________________


Dates In Unit/UnitLocation/MOS#/Job Description/What Platoon


________________ ____________ ______________________ ________________ _______________


________________ ___________ ______________________ _________________ _______________


Other units/companies you were with while in Vietnam:

Dates In Unit/UnitLocation/MOS#/Job Description/What Platoon


________________ ____________ ______________________ ________________ _______________


117th ASSAULT HELICOPTER COMPANY VIETNAM ASSOCIATION

MEMBERSHIP DUES: ANNUAL - $15.00 OR LIFE MEMBERSHIP - $150.00

MAIL TO: 117TH AHCVA

c/o ALLEN BENNETT 2483 DAVIS RD. DeFUNIAK SPRINGS, FL 32433-0051


PLEASE MAKE CHECKS PAYABLE TO: 117TH AHCVA





Employee 1

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Employee 2

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Employee 3

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Employee 4

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