MEMBERSHIP
APPLICATION
New______ Renewal______ Lifetime_______
Yearly________(check one)
Name: ____________________________________ DOB:
___________ Age:_____
Spouse: ___________________________________ DOB:
___________ Age:_____
Address:
_____________________________________________________________
City:
Phone:
( )
_____________________ E-mail:
_________________________
Cell:
( )
________________________
In what capacity did you serve?
Pilot ___ Crew Chief ___ Medic ___
Maintenance ___ Supply ___ Door Gunner ___ Flight Ops ___ Clerk ___ Commo ___
Cook ___ (check one or more)
Rank ___________
Branch of Service
______________________
Dates of Assignment (Mo/Yr-Mo/Yr)
________________________________
_____________________________________________________________
Attachments_________________________________________________________
___________________________________________________________________
If this is a renewal is this a change of
address/information ?______
____ I know a former
Dustoff/Medic/Corpsman/Pilot/Nurse or other potential member and
have
listed their name, address and telephone number on the
reverse.
Enclosed is $20.00, my membership dues for one
year (
)
Enclosed is my Lifetime membership dues as
follows Age 55 and Below $100.00 (
)
Age 56-75 $75.00 ( )
Age
76 and above $50.00 ( )
(Make checks payable to Florida Dustoff
Association)
Please attach a copy of your DD-214 (or provide within 90
days) to:
Roberta Neitzel, Treasurer,