If you prefer to mail your application, please click MS Word Format or PDF Format for the hard copy form.
C O N F I D E N T I A L
 
Counterparts
Tuong Huu Ðông Nam Á
555 W Saddle Dr
Grand Junction, CO USA 81507
Membership Application Form
 
Category:
Publish Data in Member Directory Do Not Publish Data in Directory
Publish Data On Member Only Web Site Do Not Publish Data On Web Site
  Last Name First Name Middle Initial/Sobriquet
Name:
Address: Street or PO Box
 
  Town/City, State/Province, Country & Postal Code
 
Telephone: E-Mail:
Agency or Branch: (Make sure to use correct capitals/lowercase for AOL addresses)
For. Country: Duty:  
Assignment Specifications
Dates:
Place:
Unit/Agency:
Supervisor:
Counterpart:
Distinctions:
 
Copies of documentary evidence of your advisory service and your check for $45.00 USD must be mailed to Counterparts to apply for Plenary Membership and $360.00 for Life Membership.
 
Other Information & Comments
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.
 
Application Date: Signature:
 
C O N F I D E N T I A L