We invite you to join us in the campaign to win full U.S. recognition and equitable VA benefits for our Filipino American WWII veterans through a realistic step-by-step strategy.

Members must be able to dedicate enough time to participate and to make a difference in our action oriented organization in support of our champions
in the U.S. Senate and in Congress.

How Can You Join?

Print & fill-out this form. Cut & paste. Mail with your membership dues.

 

I want to join the Equity campaign!
for a Veteran or Applicant

1)  Last Name: ________________ First:______________
2)  U.S. Organization: ___________________________
      Referred by:____________
3)  Address: _____________________________________
4)  City: ____________________ State: ___ Zip: _______
5)  Day Phone: ( ___)_______ Home Phone: (___)________
6)  Fax/E-mail:_________________ Birth Date: __ /__ /__ 
7)  Membership DUES:      (__) $100 FAMILY
    (__) $50 LIFE gets ACFV ID card & U.S. Pin/Tie/Scarf
    (__) $100 FAMILY or ORGANIZATION or more $________ 

          We accept PAYPAL & VISA Card payments
8)  YES, I pledge to recruit (__) supporters and

     to write (__) to my President and Congress members.
9)  YES, (__) I like to order a VHS VIDEOTAPE of "Fil-Am Vet in Action"

     for additional $25.00
                    Filipino WWII VETERAN's Survey 
                Please answer relevant questions
10) Vet's Social Security No: ______/ ____/_____  Awards?:______

11) Marital Status: (__) Single      (__) Married    (__)Widow
      Does Spouse live with you?(__) YES (__) NO
12) Spouse Name:_______________Age:____ Number of Children? ___

   NAMES of ADULT CHILDREN with approved US immigration petitions:

   ________________________ Age:_____ Spouse_______________

   ________________________ Age:_____ Spouse_______________

   ________________________ Age:_____ Spouse_______________

 

13) Vet's Health condition? (__) Poor (__) Fair (__) Good

     - Illnesses? _________________________
14) Has U.S. military service certification from St. Louis, MO? (__)YES
15) Date of service: ___/___/___ HONORABLY
      discharged on: ___/___/___ Serial No.:__________
16)  Category? Philippine Commonwealth Army (__)
       Old Phil. Scouts (__) Recognized Guerrilla (__)
       USAFFE (__) New or Special Scouts (__) Unit? ______________
17)  Do you have a U.S. VA HOSPITAL ID? (__) YES (__) NO
18)   Have you applied for VA COMPENSATION benefit

        from the U.S. VA Dept. for your war related injuryor illnesses

        OR a U.S. VA PENSION?( __) YES (__) NO
19)  Have a U.S. VA comp & pen claim number?Number:______
20)  What war related service-connected illnesses did you claim?
      Wound?: __________________Illness?: _________________

      Prisoner of war?: (__) YES           Bataan Death March? (__) YES
       Corregidor defender: (__) YES
21) What is your VA compensation rating (percentage)?
       ________% How much? $_____monthly
22) How much Supplemental Security Income (SSI)
       did you receive? $ _________ month (__) NONE
23) Where did you apply for SSI-Medicaid-food stamps? 
       ____________(city) When? ___/ ___/ ___/
24) Name of your bank or U.S. savings institution? _______________
25) Are you receiving Medical or Medicaid benefits

       from the U.S. government? (__) YES (__) NO
26)  How much RETIREMENT income do you get? $______ per month
27)  Would you choose to RESIDE in the Philippines?

       (__) YES (__) NO WHEN?: __/__/__
28) PHILIPPINE Address:__________________________

        Town/City: __________________
29) Are you registered to vote in the U.S.?
       (___) YES (___) NO City registered in: __________
30) Comments & suggestions? _______________________________________________
Information provided will be kept CONFIDENTIAL
Todays date:________

MAIL to: American Coalition for Filipino Veterans, Inc.
        (a non-profit advocacy & membership organization    registered U.S. House of Representatives Lobby No. 336-89000)

           For information, call: 202 246-1998