MEMBERSHIP APPLICATION FOR THE DISABLED AMERICAN …
MEMBERSHIP APPLICATION FOR THE DISABLED AMERICAN VETERANS
LIFE MEMBERSHIP AMOUNTS
Age and Amounts: 80 years and older FREE
71 – 79 $140.00
61 – 70 $180.00
41 – 60 $230.00
40 and under $250.00
$40.00 down for life membership
|Age: | |
|Name: | | | |
| Last Name First Name Middle Initial |
| |
|Street Address: | |
| |
|City/Town: | |State: | |Zip Code: | |
| |
|Telephone number: | |( Male ( Female |
| |
|Date of Birth: | |Branch of Service: | | |
| |
|Rank: | |Date Enlisted: | |Date Discharged: | |
| |
|Percentage of service-connected disability: | |% |
| | | |
|Purple Heart: |Yes | |
|Sponsor’s Name/Code Number: | |
| | |
|Chapter Name and Number requested (if known): | |
| | |
|Spouse’s Name (optional): | |Spouse’s Date of Birth: | |
PAYMENT INFORMATION
(Please make checks/money orders payable to: Disabled American Veterans (DAV)
Amount: $
( Check ( Money Order
Credit Card:
( MasterCard ( VISA ( Other:
|Card Number: | |Expiration Date: | |
| |
|Signature: |_____________________________________ |Date: | |
-----------------------
Disabled American Veterans
Department of Arizona
38 W Dunlap Ave
Phoenix, AZ 85021
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