USSVI
United States Submarine Veterans, Inc.
Buffalo Base
                           Membership Application
Our Creed:
"To perpetuate the memory of our shipmates who gave their lives in the pursuit
of their duties while serving their country. That their dedication, deeds and
supreme sacrifice be a constant source of motivation toward greater
accomplishments. Pledge loyalty and patriotism to the United States Government."

Name: (Last,First,M.I.,"Nick"):_____________________________________________
Address:____________________________________________________________________
City: _________________________ State: ____________ Zip: ___________________

Phone #: Home: ____________________ Work:__________________ 
E-mail: ___________________________________________________
Date of Birth: _____/_____/_____ Enlistment date: _____/_____/_____  
Discharge date: ____/_____ Total Years of service: ______ 
Retired(Regular)____ Retired(Reserve)____ Highest Rank/Rate: _______
Qualifying Boat Name: ______________________________  Hull number: _________
Rank/Rate at qualification: ___________________________ Date: _____/_____
Other boat(s) and hull number(s): 
(If more, check here ____ and add to back of this page)
______________________________________________ (year) _____ to (year) ______ 
______________________________________________ (year) _____ to (year) ______ 
______________________________________________ (year) _____ to (year) ______ 
______________________________________________ (year) _____ to (year) ______ 
______________________________________________ (year) _____ to (year) ______ 
______________________________________________ (year) _____ to (year) ______ 

Spouse's Name: _____________________________  
(optional) Spouse's birthday: _____/_____ 
(optional) Next of Kin Name: _______________________________________________ 
(optional) Next of Kin Address: ____________________________________________

Please check appropriate line below:

__ New Applicant                                      Date: _____/____/____
__ $40 First year membership ($30 National + $10 Annual Buffalo Base dues)
__ $10 Multiple Base Member (Annual Buffalo Base dues) Your Primary base? _____
__ $100.00 National Life Membership (age 76 or older)+$10 Annual Buffalo Base dues
__ $200.00 National Life Membership (age 66-75), plus $10 Annual Buffalo Base dues
__ $300.00 National Life Membership (age 56-65), plus $10 Annual Buffalo Base dues
__ $400.00 National Life Membership (age 46-55), plus $10 Annual Buffalo Base dues
__ $500.00 National Life Membership (age under 45) +$10 Annual Buffalo Base dues.
"I subscribe to the creed of the United States Submarine Veterans, Inc. 
and agree to abide by all by-laws, regulations and procedures governing the 
U.S. Submarine Veterans, Inc., so long as they do not conflict with my military
or civil obligations."

Signature: _________________________________________   Date: _____/_____/_____

Please make checks payable to USSVI Buffalo Base   
and mail with this application to: 

United States Submarine Veterans, Inc. 
ATTN: Neil Bellenger, (Buffalo Base Treasurer)
1 Morningside Park,
Pittsford ,New York 14534-9707                                   Rev. 3/30/06