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| Online Registration Form |
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Veterans Details (Personnel Information) |
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Veterans Name |
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Your Email |
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Postal Address |
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City/ Town |
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Australia |
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Country |
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New Zealand |
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Area Code |
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Phone |
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Mobile |
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Fax |
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Regimental No# |
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Ethnic origins |
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DOB |
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Gender |
Please select an item. |
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Veterans Detail of Service. |
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Units Served within Vietnam & what year )Include Multiple Tours & Times |
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Veterans Medical conditions |
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List of War related accepted medical conditions & % rate |
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Spouse / Partner or Mother of a child of a Vietnam Veteran |
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Full Name |
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DOB |
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Health Issues |
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Deceased Family & Known Causes |
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Full Name |
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Birth |
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Death |
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Health Issuses & Known Causes of Death. This is vital detail |
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Registration Fee |
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Bank Details (please complete)
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| The NZ Registration fee $ 25.00 NZD can be paid at: |
The Australian Registration fee $20.00 AUD can be paid at: |
VVAG Westpac account Levin NZ |
VVAG Commonwealth Bank Nerang |
Account name Vietnam Veterans Action Group
BSB 03 0667 account number 03 56793-00 |
Account name Vietnam Veterans Action Group
BSB 06 4451 Account number 10316809 |
Registrants please complete registration form and send a copy of the registration payment receipt to : |
| NEW ZEALAND RESIDENTS |
AUSTRALIAN RESIDENTS |
VVAG
- 65 Queenwood Road
- Levin 5510
- NZ
- Marked attention Ian Barnes
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VVAG
- P.O. Box 702
- Burleigh Heads
- Qld 4220
- Australia
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| The fee covers all the family members and descendants of the Veteran. Any deceased veteran’s family, the fee is waived. The fee is to help cover the costs of running the organisation and the set up of a reliable data base |
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Your Additional Comments |
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Addition remarks
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