KENILWORTH VETERANS CENTER
MEMBERSHIP APPLICATION

Membership Requirements: DD-214 / Military ID Card

Name:_______________________________________________________________________________________
                    Last                                                            First                                            Middle

Present Address:_____________________________________________________________________________

City_______________________________________State__________________________Zip Code___________

Date of Birth:________________________________Home Phone:______________________________________

Branch of Service:____________________________Date of Service:____________________________________

I certify that I am a citizen of the United States, that my service was Honorable, that I have never subsequently been discharged from Military or Navel service under dishonorable conditions.  I further state that I believe in God

Date Signed_____________Signature of Applicant_____________________________________

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Membership Committee
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The Investigating Committee has performed its duties and recommends

Election:______________________________                           Rejection:_____________________________

Signature of Committee Below

Committee Member:____________________________________________________________________________

Committee Member:____________________________________________________________________________

Committee Member:____________________________________________________________________________

Admission Fee:  $10.00                                            Dues: $15.00                            DD-214 attached Yes - N0

Member Number_______________

Print this form and mail to:

Kenilworth Veterans Center
33 So. 21st Street
Kenilworth, N. J. 07033