Membership Application
Enclosed are my dues payment $__________ for 2010 ($15.00 per year)
$__________ for 2011 ($15.00 per year) $__________ for 2012 ($15.00 per year)
Name:_______________________
Address:______________________________
City:______________________ State:_______ Zip:_____________
Telephone Number:_____________________
Email Address:_________________________
Dates served on the Antietam______________
Please submit the above information.and the dues payment to :
USS ANTIETAM ASSOCIATION
c/o L. Ray Young
140 N. Edgemoor
Wichita, KS 67208
Division while on the Antietam ____________________
If you use two addresses (e.g. summer/winter)
Please indicate the dates you use each of them
