Application / Roster form

       Last Man Club of  Vietnam War Era

                         of Saint Peter

 

                                                    Member #__________  

 

Name:___________________________________________

 

Address:__________________________________________

 

_________________________________________________

 

Signature:_________________________________________

 

E-mail address_____________________________________

 

Home phone:______________Mobile phone:_____________

 

Branch of Military__________________________  Purple Heart    (   )

 

Date entered Service________________________________

Date discharged from Active Duty______________________

 

(to be completed at the appropriate time)

Date of death:_____________________________________

 

Please include a copy of your DD214

 

Life Time membership Dues:  $20.00

      (checks  made out to:  Last Man Club of Vietnam War Era)                    

                                                                                                                 6/01/11A

 

                Proud to be a Veteran