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.

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
1a	Include in Print Member Directory
1b	Do Not Include in Print Member Directory
2a	Include in Member Only Web Site Area
2b	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	Honor & Citation 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, US Form DD214 and evidence of Advisory Service 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