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Membership Application Jayhawk Chapter |
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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 |
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Spouse | |||||||
Street Address |
Apt # |
Phone |
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City |
State |
Zip +4 |
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Birthdate |
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* Name of Deceased Officer |
Rank |
PLEASE CHECK APPROPRIATE BOXES:
Member of National MOAA? ___ Yes___ No |
___ Army |
___ USA (Regular) |
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If yes, your card number please ________________ |
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___ AUS (Reserve/Nat'l Guard) |
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___ Navy |
___ USN (Regular) |
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___ USNR (Reserve) |
___ Male |
___ Active Officer |
___ Air Force |
___ USAF (Regular) |
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___ USAFR (Reserve) |
___ Female |
___ Retired Officer |
___ Marine Corps |
___ USMC (Regular) |
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___ USMC (Reserve) |
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___ Former Officer |
___ Coast Guard |
___ USCG (Regular) |
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___ USCG (Reserve) |
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___ Public Heath Service |
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___ NOAA |
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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