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MEMBERSHIP APPLICATION FORM

Todays Date date_range

First and Last Name *

Date of Birth:

Address:

City/Town and Province/State

Email Address *

Telephone No.

Next of Kin:

Military Service Enlisted Date: date_range

Military Service Release Date: date_range

Regimental No. and Rank

Choose Service:

Specify other services:

Are you a member of any other Veterans Organization: Yes No

Specify Veterans Organization:

I agree: * Yes

Additonal Information

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