Name and Address:
Name:_______________________________________
Street:_______________________________________
City:_______________________ State:________ Zip:____________
Phone:___________________ E-mail Address:___________________
Vietnam Information:
Nickname in Vietnam:_______________________________________
Rank:___________ Position or Specialty:_____________
Brigade:___________ Regiment/Battalion:_____________
Company:__________ Platoon:___________ Squad:_____________
Dates of Service in Vietnam: From_____________ To_____________
Significant Event(s): _______________________________________________________
________________________________________________________________________
Service #___________ Hometown:__________ Home State:______
Personal Information:
Date of Birth:_________________
Occupation:________________________________________
Spouse's Name:______________________________________
Date:__________________ Signature:_______________________________________
Membership Fees: [ ] $25.00 Annually or [ ] $150.00 Lifetime Membership
Please make check payable to Hill 4-11 Association and mail it along with this application form to:
Hill 4-11 Association
ATTN: Dick Hill, Treasurer
630 Woodside Dr.
Kent, OH 44240-2664