[Print this page; fill out the form; then mail to the address at the bottom.]

USS Canopus Association

Membership Form

This information is strictly for the sole use of the USS Canopus Association and will never be

used for commercial purposes.

Name:

Address:

City: State: Zip:

Telephone number:

Email address:

Years served: to

Rate/Rank:

Ship’s Division/Shop:

Nickname aboard ship, if you had one:
______________________________________________________________________

Dues AS-9 and Widow/Widower Honorary Members: Free

If you wish to support the USS Canopus Association, please forward the following dues.

Lifetime $100 ………………………………………………………. $ _________

You will be sent a USS Canopus Lifer membership card.

New member $20 ………………………………………………………. $ _________

Renewing for 2009 $10 ………………………………………………………. $ _________

Renewing for 2010 $10 ………………………………………………………. $ _________

Renewing for 2011 $10 ………………………………………………………. $ _________

In return for paying any of the above dues, you will be sent one free challenge coin or keychain.
Circle the style you prefer:  coin    keychain

If you need more information, feel free to call me at 503-689-1712 or email me at usscanopus@mail.com.

Please make your check made payable to the USS Canopus Association and send to:

USS Canopus Association

c/o Richard Retin

2245 Wintercreek Way SE

Salem, OR 97306

For those shipmates that had more than one tour of duty aboard the Canopus.

Tour 2

Years served: to

Rate/Rank:

Ship’s division/shop:

Tour 3

Years served: to

Rate/Rank:

Ship’s division/shop: