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MEMBERSHIP APPLICATION
101st Airborne Division Association, Inc.
P.O. Box 101, 7698 State Route 41, Bentonville, Ohio 45105
Tel: (937) 549-4326 Fax: (937) 549-2018
APPLICANT'S INFORMATION
Home Tele ( ) ____________________ Work Tele ( ) ___________________
Please Check Applicable Remarks ( ) Renewal ( ) New Member ( )Reinstatement ( ) Address Change
( ) Enclosed is $20.00 for one year membership which includes six issues of the Screaming Eagle Magazine.
( ) Enclosed is $101.00 for a Life Membership that does not include the Screaming Eagle Magazine. Members must pay a subscription fee of $10.00 per year to obtain the Screaming Eagle Magazine.
Name ___________________________________ Street ____________________________
City _____________________________ State __________ Zip Code_________________
101st Unit: CO ______BN _____ Major Unit __________ WWII ____ VN____ DS____ FC____
Other Units __________________ Dates of 101st Service: From __________ To ____________
Present Occupation ______________________________________ ( ) Single ( ) Married
Spouse's Name ______________________ YOUR SIGNATURE ______________________
Please Charge my ( ) MASTERCARD ( ) VISA THE AMOUNT OF $__________
CARD NUMBER _____________________________ EXPIRATION DATE __________
CHAPTER'S INFORMATION - (IF APPLICABLE)
NAME OF CHAPTER ____________________________________________________________
APPLICATION PROCESSED BY ____________________________________________________
CHAPTER'S SHARE WITHHELD $ _______ (Authorized $5.00 per Regular or Associate Members)
CHAPTER'S SHARE TO BE REBATED $ _______ (When dues are paid by Credit Card) BY NATIONAL SECRETARY/TREASURER UPON APPROVAL OF CREDIT CARD CHARGE
NOTE: Chapter representative should use a copy of this Reproducible Form, or a modified version which depicts the same information, when processing Membership Applications (New Members and Renewals) under the Membership Fees Sharing Program which goes into effect November 1, 1996
