Hill 4-11 Association

Membership Application Form

(Please print and then complete application form)

Name and Address:

Name:_______________________________________

Street:_______________________________________

City:_______________________  State:________  Zip:____________

Phone:___________________  E-mail Address:___________________

Vietnam Information:

Nickname in Vietnam:_______________________________________

Rank:___________  Position or Specialty:_____________

Brigade:___________  Regiment/Battalion:_____________

Company:__________  Platoon:___________  Squad:_____________

Dates of Service in Vietnam:  From_____________  To_____________

Significant Event(s):  _______________________________________________________

________________________________________________________________________

Service #___________  Hometown:__________  Home State:______

Personal Information:

Date of Birth:_________________

Occupation:________________________________________

Spouse's Name:______________________________________

Date:__________________  Signature:_______________________________________

Membership Fees:  [  ] $25.00 Annually or [  ] $150.00 Lifetime Membership

Please make check payable to Hill 4-11 Association and mail it along with this application form to:

Hill 4-11 Association
ATTN: Dick Hill, Treasurer
630 Woodside Dr.
Kent, OH 44240-2664