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 Mo/Yr from__________to__________ Rank/Rate: ___________

Signature __________________________________Application Date_______________

(circle one) NEW or RENEWAL


Name__________________________________Phone Number_____________________

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

James Hopkins, Treasurer
LST 1166
41 East Coventry Ct
Clayton, N.C. 27527