MEMBERSHIP APPLICATION
Copy and Mail to:  Polk County Chapter MOAA, PO Box 3911, Lakeland, FL 33802
Attn: Treasurer

Membership Dues $25

New Member

Name ______________________________________ Nick Name _____________

Spouse’s Name ______________________________ Nick Name _____________

Street Address ______________________________________________________

City __________________ Zip ___________ Home Phone _________________

Cell Phone _________________ E-Mail _________________________________

Rank __________ Service ____________ Member DOB ____________________

Circle Appropriate Response:
Retired / Active Duty  / Widow(er)
Regular / Reserve / National Guard / Former Officer

MOAA National Membership Number ________________________________

Scholarship Fund: Pledge $________ One Time Donation Monthly

I am interested in working on a Chapter Committee and / or Events.

Additional Information:

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