C O N F I D E N T I A L
Counterparts
Truong Huu Dong Nam A
John Haseman
5555 Saddle Dr
Grand Junction, CO 81507
970-256-9421 E-mail:
jhaseman@earthlink.net
MEMBERSHIP APPLICATION
On-Line Version, Page 1
(Click for Print Version in PDF Format )
Tour Data is requested to assist Locators & Historians document the Advisory effort in SE Asia for future generations.
Your name, address, telephone and e-mail are required to ensure we can contact you if necessary.
Your Personal Information
Name:
Street Line:
City, State & Zip :
US
AF Afghanistan
AX Aland Islands
AL Albania
DZ Algeria
AS American Samoa
AD Andorra
AO Angola
AI Anguilla
AQ Antarctica
AG Antigua & Barbuda
AR Argentina
AM Armenia
AW Aruba
AU Australia
AT Austria
AZ Azerbaijan
BS Bahamas
BH Bahrain
BD Bangladesh
BB Barbados
BY Belarus
BE Belgium
BZ Belize
BJ Benin
BM Bermuda
BT Bhutan
BO Bolivia
BA Bosnia & Herzegovina
BW Botswana
BV Bouvet Island
BR Brazil
IO Brit Indian Ocean Terr
VG British Virgin Islands
BN Brunei Darussalam
BG Bulgaria
BF Burkina Faso
BI Burundi
KH Cambodia
CM Cameroon
CA Canada
CV Cape Verde
KY Cayman Islands
CF Central African Rep
TD Chad
CL Chile
CN China
CX Christmas Island
CC Cocos (Keeling) Is
CO Colombia
KM Comoros
CG Congo (Brazzaville)
CD Congo, (Kinshasa)
CK Cook Islands
CR Costa Rica
HR Croatia
CU Cuba
CY Cyprus
CZ Czech Republic
CI Côte d'Ivoire
DK Denmark
DJ Djibouti
DM Dominica
DO Dominican Republic
EC Ecuador
EG Egypt
SV El Salvador
GQ Equatorial Guinea
ER Eritrea
EE Estonia
ET Ethiopia
FK Falkland Is (Malvinas)
FO Faroe Islands
FJ Fiji
FI Finland
FR France
GF French Guiana
PF French Polynesia
TF French Southern Terr
GA Gabon
GM Gambia
GE Georgia
DE Germany
GH Ghana
GI Gibraltar
GR Greece
GL Greenland
GD Grenada
GP Guadeloupe
GU Guam
GT Guatemala
GG Guernsey
GN Guinea
GW Guinea-Bissau
GY Guyana
HT Haiti
HM Heard & Mcdonald Is
VA Holy See (Vatican CS)
HN Honduras
HK Hong Kong, SAR China
HU Hungary
IS Iceland
IN India
ID Indonesia
IR Iran, Islamic Rep of
IQ Iraq
IE Ireland
IM Isle of Man
IL Israel
IT Italy
JM Jamaica
JP Japan
JE Jersey
JO Jordan
KZ Kazakhstan
KE Kenya
KI Kiribati
KP Korea (North)
KR Korea (South)
KW Kuwait
KG Kyrgyzstan
LA Lao PDR
LV Latvia
LB Lebanon
LS Lesotho
LR Liberia
LY Libya
LI Liechtenstein
LT Lithuania
LU Luxembourg
MO Macao, SAR China
MK Macedonia, Rep of
MG Madagascar
MW Malawi
MY Malaysia
MV Maldives
ML Mali
MT Malta
MH Marshall Islands
MQ Martinique
MR Mauritania
MU Mauritius
YT Mayotte
MX Mexico
FM Micronesia, Fed Sts
MD Moldova, Rep of
MC Monaco
MN Mongolia
ME Montenegro
MS Montserrat
MA Morocco
MZ Mozambique
MM Myanmar
NA Namibia
NR Nauru
NP Nepal
NL Netherlands
AN Netherlands Antilles
NC New Caledonia
NZ New Zealand
NI Nicaragua
NE Niger
NG Nigeria
NU Niue
NF Norfolk Island
MP Northern Mariana Is
NO Norway
OM Oman
PK Pakistan
PW Palau
PS Palestinian Terr
PA Panama
PG Papua New Guinea
PY Paraguay
PE Peru
PH Philippines
PN Pitcairn
PL Poland
PT Portugal
PR Puerto Rico
QA Qatar
RO Romania
RU Russian Fed
RW Rwanda
RE Réunion
SH Saint Helena
LC Saint Lucia
BL Saint-Barthélemy
MF Saint-Martin (French)
WS Samoa
SM San Marino
ST Sao Tome and Principe
SA Saudi Arabia
SN Senegal
RS Serbia
SC Seychelles
SL Sierra Leone
SG Singapore
SK Slovakia
SI Slovenia
GS So Georgia & Sandwich Is
SB Solomon Islands
SO Somalia
ZA South Africa
SS South Sudan
ES Spain
LK Sri Lanka
KN St Kitts and Nevis
PM St Pierre & Miquelon
VC St Vincent & Grenadines
SD Sudan
SR Suriname
SJ Svalbard & Jan Mayen Is
SZ Swaziland
SE Sweden
CH Switzerland
SY Syrian Arab Rep (Syria)
TW Taiwan, Rep of China
TJ Tajikistan
TZ Tanzania, United Rep of
TH Thailand
TL Timor-Leste
TG Togo
TK Tokelau
TO Tonga
TT Trinidad & Tobago
TN Tunisia
TR Turkey
TM Turkmenistan
TC Turks and Caicos Is
TV Tuvalu
UG Uganda
UA Ukraine
AE United Arab Emirates
GB United Kingdom
US United States
UY Uruguay
UM US Minor Outlying Is
UZ Uzbekistan
VU Vanuatu
VE Venezuela/Bolivarian Rep
VN Viet Nam
VI Virgin Islands, US
WF Wallis and Futuna Is
EH Western Sahara
YE Yemen
ZM Zambia
ZW Zimbabwe
Email:
Phone:
How do you prefer to be contacted if needed by Counterparts?:
Email
Mail
Phone
Your Military Combat Honors & Citations:
US Combat Honors & Citations Awarded to You
Received
Abbrv
Name (In Reverse Precedence Order)
POW Prisoner of War Medal
CBR Combat Inf Badge, Combat Act Ribbon
PHM Purple Heart Medal
BSM Bronze Star Medal
IBM Soldier's, Airman's, Navy & Marine Corps Medal
DFC Distinguished Flying Cross
LMM Legion of Merit Medal
SSM Silver Star Medal
DSM Army, Navy, Coast Guard Dist Svc Medal
DSC Army Dist Svc Cross, Navy Cross, Air Force Cross,
Coast Guard Cross
MOH Medal of Honor
AUS, KOR, PHL, ESP, NZL, RVN, THA, TWN Combat Medals & Citations Awarded to You
Include all from a country on one line. Separate honors & citations with a comma.
Country
Abbreviation or Name
I, the undersigned applicant, certify that this information is true and correct to the best of my knowledge
and that my service in Southeast Asia
was honorable. I authorize the Association to verify my eligibility.
I support the principles and camaraderie of the Association.
Your Initial Dues Payment and Form DD214 are required to be mailed
to complete your application.
C O N F I D E N T I A L