New Member

District:

First Name:*

Middle Name:

Last Name*

Suffix:

SSN (Last 4):

Birth Date:*

Email:*

Work Phone:

Home Phone:

Cell Phone:*

Pager:

Address:*

City	State	Postal Code
Street

VAVRS Honors:

Honors:

Life Member

Hall of Fame

Past President

Current VAVRS President

Current VAVRS Vice President

Current VAVRS Secretary

Current VAVRS Treasurer

Password:*

Confirm Password:**

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