USS Washtenaw County Veterans Association Membership Application

PERSONAL INFORMATION (Please fill out in full even if this is a renewal)

Name (Please Print) __________________________________

Mailing Address __________________________________________________________

City__________________ State _______ Zip __________

Phone Numbers:

Home ____________________ E-Mail ______________________

Work ____________________ Cell ________________________

Dates Served Aboard ____________________________ Rank/Rate: _______________

Signature __________________________________

Checks should be made payable to and mailed with the application form to:

James Hopkins, Treasurer
LST 1166
298 Crosby Lane
Rochester N.Y. 14612