Membership Application

Jayhawk Chapter

Jayhawk Chapter, Military Officers Association of America

___ Enroll me as a new regular member

___ Enroll me as a new auxiliary member
PLEASE PRINT (See * below for surviving spouse)

Last Name

First

Middle

Rank
Spouse Email

Street Address

Apt #

Phone

City

State

Zip +4

 

Birthdate

* Name of Deceased Officer

Rank
PLEASE CHECK APPROPRIATE BOXES:

Member of National MOAA? ___ Yes___ No

___ Army

___ USA (Regular)

If yes, your card number please ________________

 

___ AUS (Reserve/Nat'l Guard)

 

 

___ Navy

___ USN (Regular)

 

 

 

___ USNR (Reserve)

___ Male

___ Active Officer

___ Air Force

___ USAF (Regular)

 

 

 

___ USAFR (Reserve)

___ Female

___ Retired Officer

___ Marine Corps

___ USMC (Regular)

 

 

 

___ USMC (Reserve)

 

___ Former Officer

___ Coast Guard

___ USCG (Regular)

 

 

 

___ USCG (Reserve)

 

 

___ Public Heath Service

 

 

 

___ NOAA

 

2004 Annual Chapter Dues, Payable 1 January — $20.00 for 1st Year Regular Member ($5.00 for 2 nametags) — Free for Auxiliary Member

Dues received after September 30 will be applied to the following year. — Subsequent Regular Member Annual Dues are $20.00

New Chapter Members without previous MOAA National Membership, get first year National Membership Free.

Mail Check and Application to:

Jayhawk Chapter, MOAA

______________________________________              c/o Jeffrey O. Heeb, Secretary                     __________________________________

Signature                                                                                      P. O. Box 485                                                                                              Date

Lawrence, KS 66044-0485