[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 2006 $10 ………………………………………………………. $ _________

Renewing for 2007 $10 ………………………………………………………. $ _________

Renewing for 2008 $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

Note: Due to the way we are structured and organized, please allow two months for your check to clear.

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: