Khe Sanh Veterans Association Inc.

Membership Application

Copy, Print and fill out form. Submit completed form with dues to address below

Check one: New Member     Renewal     Change

Last Name: _______________________________________________________

First Name: __________________________________________MI: _________

Nick Name: ______________________________________________________

Street Address ____________________________________________________

City:  _____________________________State: ____Zip Code: _____________

Home Phone: ______________________Work Phone: ____________________

Fax: ____________________ Email Address: ____________________________________

Are You A Khe Sanh Veteran: Check One: Yes No

If Yes: What dates were you at Khe Sanh: _______________________________________

Branch of Service: USMC:     ARMY:     AIR FORCE:     NAVY: 

Unit/s:__________________________________________________

If No: What is your association with the Khe Sanh Vets:_________________________________
________________________________________________________________________________

Membership Type: Life Member: ($150.)    Regular ($20 Annual)    Associate: ($20.)
Note: On renewals, circle any item to be changed. If a request for a change in the current membership directory please complete the form, circle any item to change and fax or mail form.

Please Make checks payable to: Khe Sanh Veterans Association Inc.

Mail to:
Tom Eichler
3221 N. Opal
Chicago, IL. 60634

Phone: 773-625-2101   Fax: 773-625-8021
Email: [email protected]

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