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Membership Application

MOAA’S HISTORIC MAYPORT CHAPTER
MEMBERSHIP APPLICATION


Regular Member (Military Officers):
Full Name:_________________________/ Rank:___________/ Service__________
Dates Served: __________to__________/ Retired?: _______(Y/N)
— or —
Surviving Spouse Member:
Full Name:_________________________ Rank: __________ / Service: _________ (Fill in name, rank, & service of your deceased military officer spouse)
Please make checks for $25 payable to “MOAA’s Historic Mayport Chapter Inc”  Send application & check to 3534 Eunice Rd, Jacksonville, FL 32250 or put in Fleet Landing Social Box #116
Address:____________________________________________________________
Email:_____________________________ / Telephone#: _____________________
Spouse’s Name: ____________________/ Email: __________________________
MOAA National Member?________ (Y/N) / MOAA Life Member? _______ (Y/N)
MOAA Member #:_____________________ If you are not currently a member of MOAA, can your Chapter obtain a basic MOAA membership for you at no cost to you ______ (Y/N)
Your Birthdate:___________________/ Spouse Birthdate: ___________________ (So we may honor you both on your birthdays)
Comments / Additional Information: _____________________________________
______________________________________________________________________



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