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American Coalition for Filipino Veterans Inc.

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Download ACFV Membership Form

OR, click on the DONATE button above to pay your $50 LIFE MEMBER or $100 FAMILY Membership dues with your credit card now!
 
You will get a receipt by e-mail and on your monthly statement.
 
Who Can Join?
We invite you to join our campaign to win full equitable VA benefits for our Filipino American WWII veterans and their dependents with a realistic step-by-step strategy.

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

           867 North Madison St., Arlington VA 22205

           For information, call: 202 246-1998