Chapter: _____________________ State: __________________ Members Card Number: __________
First Name: _______________ Last: ______________________ MI: _____ Rank/Rate:______________
Address: _______________________________________________ Service No.:
_________________
Birth Date: __________________
City: _____________________State: ______ Zip: _______________ Phone
No.: __________________
Occupation: __________________
Boats, Relief Crews (Underline WW II)
Service Dates: ________________
_____________________________________________________
Sub. Service Dates: ____________
___________________________
_____________________________________________________
___________________________
Type of Military Service prior to
_____________________________________________________
Sub Duty
___________________________
_____________________________________________________
___________________________
___________________________
_____________________________________________________
___________________________
Nickname: ______________________ Social Security Number: _______________________________
Special awards other than Campaign Medal awards &
why received Service after Submarine Duty
__________________________
_____________________________________________________
__________________________
Marital Status: ______________
_____________________________________________________
Wifes Name: _______________
List Chrildren in order of age, oldest first with Birthdate:
Next of Kin: _______________
__________________________________________
______________________________________
__________________________________________ ______________________________________
__________________________________________ ______________________________________
__________________________________________ ______________________________________
Charter Member: ____________ National: _____________State: ____________ Chapter: ____________
Offices held in Organization: ________________________________ ___________________________
Blood Type: _______________________ Member of Blood Bank?: _____________________________
Wifes Birthdate: _________________________ Anniversary Date: ______________________
Remarks: ___________________________________________________________________________
___________________________________________________________________________________