189th
ASSAULT HELICOPTER COMPANY ASSOCIATION
Membership Application
October
1, 2007 September 30, 2009
or
Life
Time
Membership
Name:______________________________________DOB:
_________________
Nickname:
_______________________________
Name
of Spouse:____________________________DOB: _________________
Address:_________________________________
City:______________________/State__________/Zip__________
Home
Phone:____________________Cell:______________
E-mail
Address:_____________________@___________________
Dates
in 189th, 604th, 6th Signal 519th
Med? Please circle
Dates/Units_____________________________
Other
Units:
Crew/Position:___________________________
CALL
SIGN: ______________________________
If
you still are working, please list the name of the business:
__________________________________________________
Work
Phone:__________________________
Membership
Dues for two year. $25.00:
____________
(October
2007 – September 2009)
Life
Time Membership
$250.00: ___________
or
5 Payments of $50.00
___________
TOTAL AMOUNT ENCLOSED: $____________
Please
make the check out to the 189th AHC Assoc., and mail to:
Gerry
Sandlin
189th
AHC
9559 E. 38th
LN
Yuma
,
AZ
85365
If
you have any questions, please contact Gerry 928-344-5613 or