Name:       E-mail Address:

                    Last, First, Middle Initial

Address:               Home Phone:

                                         Work Phone:

                          City                                                                  State     Zip Code

References:

    Please provide information for three persons not related to you who know your qualifications:

  Name                                                       Address                                                                                  Phone                                     Relationship

Criminal Background:

     Have you ever been convicted of a criminal offense in any state, not including traffic violations?       Yes      No

     If so, please explain:

Desired Field:

    Please select the field(s) in which you are interested in participating  (for informational purposes only, select all that apply)

  Soldier          Civilian          Musician          Medical

Best Time to Contact:

     When is the best time for the unit to reach you?       Morning Afternoon Evening     Best method of contact:  Home Phone Work Phone E-mail

Membership Type: (select one)

   Full Membership       Hereditary Membership (Do not plan to attend events)

Unit Dues:

     Unit dues are $25/person/year, which includes insurance. The dues also guarantee a subscription to the unit's monthly newsletter, the Goober Grabber. Payment of unit dues will be arranged after acceptance into the 21^st Georgia.

21^st Georgia Volunteer Infantry

"Never Call Retreat"

 By submitting this application, you acknowledge that you have read through the entire application and that all information contained herein is accurate. This information will remain within the 21^st Georgia Volunteer Infantry and will not be provided to any third party.