USS Antietam Association 
Membership Application
Name:_________________________________
Address:_______________________________
City:___________________________________  
Telephone Number:_____________________
Email Address:_________________________
Dates served on the  Antietam____________
Division while on the Antietam ____________
If you use two addresses (e.g. summer/winter)
Please indicate the dates you use each of them.
Please mail application and dues payment to:

USS Antietam Association
Tony Vacca,
44888 N. Gateway Drive
Medina Township, OH 44256
State:__________________________________
Zip Code:______________________________
Enclosed are dues payment(s)  $___________for ________
                                                                        (Year) or (Years)

(Dues are $15.00 per year.)

Check payable to: USS Antietam Association