ATTENTION: New members and new life members

            You must submit a copy of your DD Form - 214 form

            along with this application and dues payment.

Name _______________________________________________________________________

Address _____________________________________________________________________

City _________________________________________________________________________

Home Phone __________________________ Work Phone __________________________

Email Address _______________________________________________________________

Date of Birth __________________________ Sex __________________________________

(OPTIONAL) Chapter number _______________ Sponsor ___________________________

                  ( ) I am already a VVA member and want to become a life member.

                      My VVA Member number is ________________________

Type of membership:

  ( ) Individual Member - 1 year:  $20     ( ) Life Member - Ages 49 and under:  $250

  ( ) Individual Member - 3 years: $50     ( ) Life Member - Ages 50 - 55: $225

                                                              ( ) Life Member - Ages 56-60: $200

                                                              ( ) Life Member - Ages 61-65: $175

                                                              ( ) Life Member - Ages 66 +: $150

                          ( ) Optional Time Payment plan - $50 down, $25 monthly

Payment Method:

            ( ) Check   ( ) Money Order  ( ) Credit Card (Visa, Mastercard, Amex, Discover)

 Credit Card Number: ___________________EXP. DATE:______   

Signature ______________________________________________

Return completed application to VVA Mesquite Chapter 993 / P O Box  2431/ Mesquite, NV 89024-2431