Membership Department
DAV National Headquarters
P.O. Box 145550
Cincinnati, OH 45250-5550
(DO NOT send via E-Mail!)

_________________________________________________________________________
Last Name                     First Name                   Middle Initial

_________________________________________________________________________
Spouse’s First Name

_________________________________________________________________________
Street Address

_________________________________________________________________________
City                          State                        Zip

____ Male   ____ Female


Birth Date: _______________  Social Security Number: _____-____-_________

____________________  ____________________  _____________________________
Date Enlisted         Date Discharged       Branch of Service       

____________________  ____________________
Rank                  VA Claim Number

__________________________________________  (______)_____________________
Signature                                   Telephone Number

____________________________ @ ______________
Your E-mail Address

Amount Paid: For more information, go to Membership Dues.

____ Annual Membership ($20.00)

____ New life membership (Minimum $20.00 down)     ____ Life payment

Please list your chapter number and location:  Longmont Chapter #16

I have a service-connected disability rated at ________% (0% - 100%)

Did you receive a Purple Heart?  ____ Yes   ____ No

Are you an Ex-P.O.W.?            ____ Yes   ____ No

___________________________________________________   ___________________
Signature                                             Date

Arnold E. Colcleasure, Jr. 05016L13464                (303) 776-8905  
Sponsor’s Name and Code Number If Applicable           Telephone Number

____ My check is enclosed or

____ Charge my credit card:  ____ Master Card    ____VISA

________________________________________________      ___________________

Card Number                                           Expiration Date