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:

______________________________________________________________

______________________________________________________________

______________________________________________________________

Contact Us Today!

Imperial Polk County Chapter of MOAA
PO Box 3911
Lakeland, FL 33802


Phone: 863 602-0921

E-mail: gary_clark44@hotmail.com

Print Print | Sitemap
WEB Master; Joe McDonough, Created with 1&1 WebsiteBuilder