DAV Chapter Application

The cost of a life-long membership in the DAV is as follows and may be paid in interest-free installments over three years following a minimum $20.00 down payment:

Age 71 and over ........... $75	Membership Rockville Memorial Chapter#12 inc. P.O. Box 67 Rockville, MD 20848-0067
Age 61 - 70 .................... $100
Age 41 - 60 .................... $125
Age 40 and under ........ $150

_________________________________________________________________________
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:

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

Please list your chapter number and location (if known): __MD CH 12_____________________

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

Disability Retirement from Military?                  ____Yes     ____No
Did you receive a Purple Heart?                        ____ Yes   ____ No
Are you an Ex-P.O.W.?                                        ____ Yes   ____ No

___________________________________________________      ___________________
Signature                                                                                                            Date

___________________________________________________      ___________________
Sponsor’s Name and Code Number If Applicale                                         Telephone Number

____ My check is enclosed or

____ Charge my credit card: ____ Master Card    ____VISA

________________________________________________         ___________________
Card Number                                                                                                  Expiration Date

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DAV Chapter Application

Rockville Memorial Chapter#12 inc.

P.O. Box 67