9509 Coolbrook
San Antonio, TX 78250-3440

APPLICATION FOR MEMBERSHIP

NAME...............................................................            Date...........................

Address.............................................................            City/State/Zip Code........................

E-mail Address..................................................            NickName.....................................

Telephone No....................................................            Date of Birth...................................

Spouse or Next of Kin.......................................            Check one Spouse()Son()Daughter()

Date Enlisted (called to active duty)....................            Branch of Service............................

Date Discharged................................................            Social Security Number...................

Unit Assigned on Bataan....................................            Date of Service on Bataan................

VA Claim No....................................................            Where Captured and Date...............

List POW Camps..............................................            Rank at the Time of Capture..............

IF NOT A SURVIVOR OF BATAAN, PLEASE STATE WHY
YOU WANT TO BE A MEMBER.
 
 

TYPE OF DUES:           ACTIVE ($10.00) NEXT OF KIN ($15.00) HONORARY ($20.00)

PAYMENT RECEIVED...................        DONATION TO SPECIAL PROJECT..................

ALL ACTIVE MEMBERS MUST HAVE SERVED ON BATAAN
DURING THE PERIOD 2 JANUARY 1942 AND 9 APRIL 1942.
A FALSE APPLICATION WILL RESULT IN DISMISSAL OF
MEMBER.

SIGNATURE AND DATE,

______________________________    ______________________________