Membership Application

If this is a RENEWAL, you only need to complete required fields shown in red and payment fields.
                  If any other information has changed, please update those fields at the time of renewal.

This is a:New Application     Renewal

Date:        Date of Birth: 
Rank/Title:    Status:  Active Duty Reserves Retired Civilian
First name: M.I. Last name:
Suffix:    Branch: 

Mailing Address:   
City: State: Zip:
Home Telephone:  Work Telephone : 

**We do not require 2 email address but highly recommend that you provide a work
and personal email if possible.  This ensures that you receive updates if you
PCS or your command/organization has a firewall.  Thank you!
Primary E-Mail Address:      
Alternate E-Mail Address: 
Duty Station or Employer: 
Position/Billet: 


Sponsor: 
Chapter Affiliation: PLEASE SELECT ONE Annapolis Arabian Gulf Bath, Maine Charleston Coastal Bend Dahlgren Great Lakes Greater New York Greater Washington(D.C & Northern VA) Hampton Roads Korea Mayport/Jacksonville MidSouth (Memphis, TN) Monterey Naples/Gaeta New London, CT New Orleans Newport Pascagoula Pearl Harbor Philadelphia Puget Sound San Diego Sasebo Tampa Bay USS CONSTITUTION Yokosuka
Non-Affiliated        Other (specify)

 MEMBERSHIP FEES:    
 

Promotion Code (If Applicable): 

LIFE MEMBERSHIP DUES (PAYMENT PLANS ARE AVAILABLE)
Active Duty and Drilling Reserve to age 50:      $350
Active Duty and Drilling Reserve after age 50:  $250

Retired or Civilian:

Gift Membership from:   
Sponsor from: 

Payment Information

Total Payment:  $

Check     Visa   MasterCard  AMEX
Credit Card Number: 

Expiration Date: 

Name as it appears on card: