Name:___________________________________________________
(Last , First MI)

DOB__________________
 (M/D/Y)

Street:________________________________________________________________
City _______________________________
State ______________________________
Zip ________________
Telephone _______________________

Sponsored by:
Bill Wells, GMCM, USCG(Ret)
258 Meadowlake Drive
Martinez, GA 30907
Email:wrw2@earthlink.net

Do you have two addresses? (Circle one) Y N
If yes, please include address.

Address #2___________________________________________________

Telephone #2:________________________________________________

IMPORTANT: This application MUST be accompanied by either a copy of your Discharge (both sides); or a DD-215/214; or NAC/CG-553, or some other official documentation that states your participation in or your support of a combat mission. You may also obtain a certified (not notorized) statement from a former shipmate who is a member of the CGCVA in "Good Standing (current)" stating you served with him or her on a particular ship or station during the claimed time and area of operations.

DUES: $25.00 for Two (02) Years. Make Check or Money Order

Payable to:
CGCOMVETS

Signature ________________________________________ Date_____________

Send Application and Dues To:
CGCVA Administrative Office
PO Box 544
Westfield Center, OH 44251 Message or FAX: (850) 651-3664
Membership Inquiries Only: 866-242-8277
Email:cgcva@hotmail.com

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