NABVETS DE Chapter 94 Membership Application

Membership Status:

Membership RenewalMembership Card NeededNew Member
Prefix:
Name:

First NameMiddle InitialLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Cell Phone:
Please enter a valid phone number.
Home Telephone:
Please enter a valid phone number.
Work Telephone:
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
Gender:

MaleFemaleOther
Present Status:

Active-DutyReservistNational GuardRetiredVeteran (180 days with honorable discharge)Veteran (honorable discharge)Veteran (other than honorable discharge)Non-Veteran (non-veterans are Associate Members)
Branch of Service:
Type of Discharge:
Service Dates:
Attached is a copy of my

DD214Veterans ID
Referred by:
Chapter and Region Affiliation:
Currently Employed? (optional)

YesNo
Occupation: (optional)
Company: (optional)
Other Memberships: (optional)
Race/Ethnicity: (optional)

African AmericanAlaskan NativeAsianCaucasianHispanicNative AmericanNative HawaiianPacific IslanderLatinoOther
Membership Types:

$40 Annual Membership$70 Two-year Membership$95 Three Year Membership$300 Silver Life Membership$600 Gold Life Membership$1,200 Diamond Life MembershipAdditional Tax-Deductible Contribution of $______
I hereby attest that I will abide by the principles and policies of the National Association for Black Veterans, Inc., and to the utmost of my
abilities, assist in promoting positive lifestyles for veterans, their family members, and the community, with a particular emphasis on the
unmet needs of minority veterans and youth development.
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