USS FULTON AS-11 ASSOCIATION

Membership Application

Membership dues are as follows

Annual/Associate $10 per year, Lifetime $150 under age 60, $125 over age 60

Make your check payable to USS Fulton AS-11 Association

Please complete the following application and mail with your check to:

Richard Hartman

25 Greenleaves Dr. #510

Amherst, MA 01002-2852

Name: ________________________________________

Address: _______________________________________

City, State, Zip: ____________________________

Phone Number: _________________________________________

E-Mail Address: ___________________________

Spouse’s Name: _________________________________________

Birthdates: (yours):______________________Spouse:_______________________

Anniversary: (mm/dd/yyyy)____________________________________________

VERY IMPORTANT, we need this information for our tax exempt status

Dates of Service in US Navy: ______________________________

Dates of service aboard USS Fulton: ____________________

Rank or Rate:  ___________________________________________

Div. or Dept. ___________________________________________