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MEMBERSHIP APPLICATION
101ST AIRBORNE DIVISION ASSOCIATION INC.
P.O. BOX 101, 7698 STATE ROUTE 41
BENTONVILLE, OHIO 45105

 

Home Tele (____)______________ Work Tele(____)______________

Please Check Applicable Remark: ( ) Renewal ( ) New Member ( ) Reinstatement ( ) Change of Address

( ) Enclosed is $20.00 for one year membership

( ) Enclosed is $101.00 for Life Membership (age 70 or older)

( ) Enclosed is $101.00 for Life Membership (under age 70)

( ) Enclosed is $50.00 for 1st of 4 Installments towards $200.00 Life Membership

Name:_____________________________

Street/RFD___________________________________________

City:__________________________ State__________ Zip Code_________________

101st Unit: CO________ BN_______ Major Unit _______ WWII_______ VN_________ DS_________ FC________

Other Units___________________________________

Dates of 101st Service: From______________ To__________________

Present Occupation_________________________________

( ) Single ( ) Married Spouses Name:__________________________________

Please Charge my ( ) Mastercard ( ) Visa in the amount of $_________

Card Number______________________________ Expiration Date_______________

Signature______________________________________________________ 


CHAPTER'S INFORMATION

NAME OF CHAPTER___________________________________________

APPLICATION PROCESSED BY__________________________________

CHAPTER'S SHARE WITHHELD $___________ (authorized $5.00 per Regular or Associate Members)

CHAPTER'S SHARE TO BE REBATED$__________ (When dues are paid by Credit Card)

BY NATIONAL SECRETARY/TREASURER UPON APPROVAL OF CREDIT CARD CHARGE

NOTE: Chapter representatives should use a copy of this Reproducible Form, or a modified version which depicts the same information, when processing Membership Applications (New Members and Renewals) under the Membership Fees Sharing Program which goes into effect November 1, 1996.