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
Sandy Haskin, Secretary/ Treasurer
57 Oak Street
Westfield, NY 14787
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State:__________________________________
Zip Code:______________________________
Enclosed are dues payment(s) $___________for ________
(Year) or (Years)
(Dues are $15.00 per year.)
Check payable to: USS Antietam Association
