Date __________________

Name: _____________________________________________________________ Gender: ___ M/F
(Please specify in order: Last name, Middle name and First name)
Mailing address: ___________________________________________________________________
                            (Street)                                                                    (City)                (State)     (Zip)
Phone: (Home) ____________________ (Work) __________________ (Pager): _______________

E-mail address: _____________________________ Occupation: ____________________________
Current employer: _____________________________________________ Years of Experience: ___
Date of birth: _____________ Place of birth: ______________________ Marital status: __________
Spouse name: ___________________________________ Is spouse also a member? Yes ___ No ___

Optional information:

Check Educational level: ___ High school ___ Undergraduate ___ Graduate
Institution: ________________________________________________________________________
Major: ___________________________________________________________________________
Diplomat/Degree earned: ____________________________________________________________
Check skills/talents: ___ Artistic & musical performance ___ Journalism ___ Science & technology
                                  ___ Other skills
If possible, please describe the above mentioned skills or talents: _____________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Hobbies: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
List other organizations of which you are a current member: _________________________________
_________________________________________________________________________________
_________________________________________________________________________________

I hereby apply for the Vietnamese Culture & Science Association membership.  I have read the association's By Law and rules and agree to abide by them.

Signature ________________________ Date ___/___/___

Membership fee - single: $20/year, couple: $25/year.  Please make check payable to The Vietnamese Culture & Science Association.