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VIETNAM WAR COMMEMORATION <br />COMMEMORATIVE PARTNER PROGRAM APPLICATION <br />(Civilian Organizations only) <br />PRIVACY ACT STATEMENT <br />AUTHORITY: 10 U.S.C. Section 113 note (Public Law 110 -181, div. A, title V, Section 598, Jan. 28, 2008, 122 Stat. 141), Program to Commemorate <br />50th Anniversary of the Vietnam War. <br />PRINCIPAL PURPOSE(S): Multiple organization points of contact and contact information are necessary to allow DoD to communicate with the <br />organization. The timeframe of the commemoration lasts 13 years. <br />ROUTINE USE(S): Any release of information outside the DoD will be compatible with the purpose(s) for which the information is collected and <br />maintained. The DoD Blanket Routine Uses found at http: / /dpclo.defense,gov/ privacy /SORNs /blanket_ routine_uses.htmt may also apply to this <br />collection. Applicable SORNs: None. Records are retrieved only by organization name. <br />DISCLOSURE: Voluntary. However, failure to provide requested point of contact information may adversely affect the organization's acceptance as a <br />commemorative partner. <br />INSTRUCTIONS <br />To apply to become a Commemorative Partner, please fill out the following information in as much detail as possible. Please type or <br />print clearly. <br />Steps: <br />1. Use this form (DD Form 2954 for military installations) to list your organization's name and provide the names, addresses, email <br />and telephone numbers of your committee's chairperson and point(s) of contact (POC), <br />2. Use Page 2 of this form to list the members of your Commemorative Committee. You may add as many as you like, but we <br />require at least three members. <br />3. Use the Submit button at the bottom of this form to email your application to: WHS .VNWAR50th_CPP_CIVAPP @mail.mil <br />fax to: 703 - 692 -4691, or mail hard copies to: <br />The United States of America Vietnam War Commemoration, Suite 810, 1101 Wilson Blvd., Arlington, VA 22209. <br />1. ORGANIZATION <br />a. NAME <br />b. TELEPHONE NUMBER (Include Area Code) <br />Cabarrus County, NC <br />704 -920 -2100 <br />c. MAILING ADDRESS: (1) STREET (include Suite Number) <br />(2) CITY <br />(3) STATE <br />(4) ZIP CODE <br />P.O. Box 707 <br />Concord <br />NC <br />28026 -0707 <br />2. COMMITTEE CHAIRPERSON <br />a. NAME <br />b. EMAIL ADDRESS <br />c. TELEPHONE NUMBER(S) (include Area Code) <br />d. MAILING ADDRESS <br />(1) STREET (include Suite Number) <br />(2) CITY <br />(3) STATE <br />(4) ZIP CODE <br />3. POINT OF CONTACT <br />a, NAME <br />b. EMAIL ADDRESS <br />c. TELEPHONE NUMBER(S) (include Area Code) <br />d. MAILING ADDRESS: (1) STREET (include Suite Number) <br />(2} CITY <br />(3) STATE <br />(4) ZIP CODE <br />4. POINT OF CONTACT <br />a. NAME <br />b. EMAIL ADDRESS <br />c. TELEPHONE NUMBER(S) (include Area Code) <br />d. MAILING ADDRESS: (1) STREET (include Suite Number) <br />(2) CITY (3) STATE <br />(4) ZIP CODE <br />5. POINT OF CONTACT <br />a. NAME <br />b. EMAIL ADDRESS <br />c. TELEPHONE NUMBER(S) (include Area Code) <br />d. MAILING ADDRESS: (1) STREET (include Suite Number) <br />(2) CITY <br />(3) STATE <br />(4) ZIP CODE <br />DD FORM 2953, DEC 2013 If additional committee members, list on Page 2, Page 1 of 2 Pages <br />PREVIOUS EDITION IS OBSOLETE. Att9¢lherF"ks umber 1 <br />F -5 Page 53 <br />