Name:_______________________________________________________

Address:_____________________________________________________

Address Line 2:_______________________________________________

City:____________________________State:_______Zip:_____________

Telephone Number:____________________________________________

Email Address:________________________________________________

Dates served on the Antietam:___________________________________

Division while on the Antietam:__________________________________

Enclosed are my dues payment:

$________________   For the year(s) of (Write applicable):

____________________________________________; ($15.00 per year)

Please submit the above information.and the dues payment to :

USS ANTIETAM ASSOCIATION
c/o Erma Booth
5406 North 37th Street
Tacoma, WA 98407