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
 
Voice: 209-723-5920       E-mail: jhaseman@earthlink.net
Membership Application (p1)
Note: Data will be posted according to No of Tours Reported
Your name, address, telephone and e-mail are required to ensure we can contact you.
Your Personal Information
Your Name:
Your Street:
Your City, State & Zip:
Your Email:
Your Phone:
How do you want to be contacted?:
Signature/Authorization:
Your Service Information
Country of Service:
Agency/Branch of Service:
Highest Rank:
No of SE Asia Tours/Assignments:
Total Years of Your Service:
Discharge Date (MM/DD/YYYY):
Discharge Type:
Tour/Dates & US MOS/Rating/NEOC (Job Identifiers):
Type Tour 1 Tour 2 Tour 3 Tour 4 Tour 5
Highest Rank          
Start Date          
End Date          
Advisory Title          
Primary          
Secondary          
Your Military Combat Honors & Citations:
Check Abbrv Name
US Medals Awarded to You
POWPrisoner of War Medal
CBRCombat Inf Badge, Combat Act Ribbon
PHMPurple Heart Medal
BSMBronze Star Medal
ISMSoldier's, Airman's, Navy & Marine Corps Medal
DFCDistinguished Flying Cross
LMMLegion of Merit Medal
SSMSilver Star Medal
DSMArmy, Navy, Coast Guard Dist Svc Medal
DSCArmy Dist Svc Cross, Navy Cross, Air Force Cross, Coast Guard Cross
MOHMedal of Honor
AUS, KOR, PHL, ESP, NZL, THA, TWN Medals & Citations Awarded to You
   
   
   
   
   
   
 
Your Southeast Asia Tour(s) of Duty
Advisory HQ Information
Tour Corps Prov/CAG City/Town Team No PSA/CAG Co Name
1          
2          
3          
4          
5          
 
Advisory Team Unit Information
Tour Dist/CACO DSA/CACO Ldr Name Team No Town/Village Sub/Mobile Tm Mobile Tm Ldr
1            
2            
3            
4            
5            
 
Advised Foreign Unit Information
Tour No Div Name Div No Bgd No Bn No Co/CAG Base Name Base Loc
1              
2              
3              
4              
5              
 
Non-Advisory US & Other Foreign Unit(s) Information
Tour No Div Name Div No Bgd No Bn No Co ID Base Name Base Loc
1              
2              
3              
4              
5              
 
Indicate Those Members & Counterparts You Would Like to Locate
Tour Locate List Advisory Team Members
( Include Rank, Full Name, Home of Record )
 
 
 
 
 
 
Tour Locate List Your Counterparts Info
( List Rank, Title, Full Name, Family Home, etc. )
C O N F I D E N T I A L