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