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))
 
The Tour(s) data is requested on the next page 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 as necessary.
Membership Category Requested:
Your Personal Information
Name:
Street Line:
City, State & Zip:
Email:
Phone:
How do you prefer to be contacted if needed by Counterparts?
Personal Data Restrictions
Include in Print Member Directory
Do Not Include in Print Member Directory
Include in Member Only Web Site Area
Do Not Include in Member Only Web Site Area
Other Information & Comments
,
Your Service Information
Your Country of Service:
Agency/Branch of Service:
Highest Rank: [Help?]
No of SE Asia Tours/Assignments:
In-Country Units/Team Nos:
Unit/Team Locations:
Total Years of Your Service:
Discharge Date:
Discharge Type:
 
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 of Citation
 
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 US Form DD214 or Non-US equivalent are required to be mailed to complete your application.
 
Signature/Authorization:
Application Date:
 
 
 
C O N F I D E N T I A L