Your Name:  required
        Member Number:  Leave blank if not a member
       Street Address: 
       Street Address: 
                 City: 
                State: 
   Zip or postal Code: 
              Country: 
        Email Address:  required
Home Phone:(Area Code) 
Work Phone:(Area Code) 
Fax Number:(Area Code) 
           
Preferred communication means with HPF committee:
          E-mail          Telephone

Title of presentation: 

Type of presentation:
Aviation Vietnam  Non-Aviation Vietnam  Author/producer

Presentation time reguested:
          30 mins    60 mins  Other: 

Special audio-visual support needed (explain):  

I acknowledge that if selected as a speaker I will submit a slide 
presentation or 3-5 page summary no later than 1 June (presentation 
must be provided for electronic loading the day before scheduled - 
changes are allowed.  Please check: YES  Initials: 

I acknowledge that if selected and scheduled to present, I will register
and attend the VHPA Reunion (speakers must make every effort to present):
Please check:  YES  Initials: 

Please provide a short biography, especially as it relates to presentation:

Questions?  Contact Dr. Jim Fulbrook, 703.385.2999, jfulbrook@cox.net, 
Fax 571.227.6009  Address: 3478 Barrister's Keepe Circle, Fairfax, VA 22031
Submit by 28 February 2006.