Associates of Vietnam Veterans of America

Membership Application

Send application, with dues payment, to:

AVVA

P. O. Box 64732

Baltimore, MD 21264-4732

Make checks payable to AVVA.

Please do not send cash.

Name: _________________________________________________________________

Address: _______________________________________________________________

City: _____________________________ State: ________________ Zip: ___________

Phone: ________________________ E-mail: __________________________________

Date of Birth: ___________________ Male / Female: (Circle One)

Dues: (Check One)

____ One Year: $20

____ Three Years: $50

____ Life Membership, age 49 and under: $250

____ Life Membership, ages 50 to 55: $225

____ Life Membership, ages 56 to 60: $200

____ Life Membership, ages 61 to 65: $175

____ Life Membership, age 66 + : $150

____ Life Membership, time payment plan: $50 down, then $25 per month

(For the time payment plan, please be sure to include your date of birth.)

Payment Method:

____ Check ____ Money Order

Credit Card:

____ VISA ____ Master Card ____ Discover ____ American Express

Credit Card Number: ______________________ Expiration Date: ______________

Signature: __________________________________________