A/1/7 MEMBERSHIP APPLICATION
FIRST NAME: _______________INITIAL:______ LAST NAME:___________________
ADDRESS: _________________________CITY:___________________ STATE: _______
ZIP CODE: __________________TELEPHONE NO:______________________________
EMAIL ADDRESS: ________________________________ NICK NAME______________
SPOUSE’S NAME:________________DATES SERVED IN KOREA _________________
*CORPSMAN USN/(R)
PLT/SQD _________ *RETIRED USMC/(R) _______ RANK_________DATE_________
ANNUAL DUES: $20.00 2006______2007_______2008_______2009______ 2010______
AMOUNT PAID: $ ________________ DISCRETIONARY FUND $_________________
THE MAILING LABEL INDICATES THE YEAR YOU WERE LAST CREDITED PAYING YOUR ANNUAL DUES. I.E., JOHN DOE: 2004, 2005, 2006 & ETC.
IF YOU DON’T UNDERSTAND WHERE YOU STAND ON YOUR DUES PLEASE GIVE ME A CALL OR SEND ME AN EMAIL!
C/o L. R. “SHIFTY” SHIFFLETTE
TELEPHONE NO: 540-434-2066
EMAIL ADDRESS: ShiftyA17@verizon.net
*Denotes: I need to have this information for our records, as sometimes I am asked this
question. Other changes are needed especially address, as well as other important data so that our personnel roster will be as accurate as possible.