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Agent Orange Widows Awareness Coalition Membership Information Form

To assist with financial support for our outreach to veterans and their families, donations of any amount are greatly appreciated. For AOWAC membership, our suggested annual membership donation is $20.00.  Make check or money order payable to AOWAC and mail to:
AOWAC
P.O. Box 92131
Long Beach, CA  90809-2131 

You will be added to our database for future correspondence.  Thank you for your support. 
___________________________________________________________________

Please provide the following contact information:
 

Your Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
FAX #
E-mail
Spouse's Name
Veteran's Name

Check related categories:
 

Vietnam Veteran	Agent Orange Widow/Widower
Veteran-Era Veteran	Active Duty Military
Korean Veteran 68-69	Retired Military
Veteran	Other

    Name of Veteran:

Name
Branch of Service:
Dates of Vietnam Service:
Dates of Korean Service:
Locations:
Locations:
Diagnosed Illness(es):
Date of Death:
Cause of Death:
VA Recognized? Yes or No

I am a:
  Widow / Widower of Vietnam Veteran
  Surviving Child of Vietnam Veteran
  Family Member of Vietnam Veteran

  Widow / Widower of 68-69 Korean Veteran
  Surviving Child of 68-69 Korean Veteran
  Family Member of 68-69 Korean Veteran

  Widow / Widower of Veteran
  Family Member of Veteran(s)
  Friend of Veteran(s)
  Friend / Supporter of AOWAC
                                   

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