MEMBERSHIP APPLICATION ______NEW ____RENEWAL

SOUTHWEST ILLINOIS CHAPTER OF THE MILITARY OFFICERS’ ASSOCIATION OF AMERICA
MAILING ADDRESS: P.O. BOX 735, O'Fallon, IL 62269

Name________________________________________________ Rank___________ Date____________
(Last) (First) (MI)
Spouse’s Name___________Telephone (____)__________ E-Mail____________________
Address______________________________________________ ________________________________
(Street) (City)/State/Zip)
MOAA (National) Membership Number________________________ Expiration Date_________________
(Required by By-Laws for Regular and Associate members)
Check Applicable Boxes:
Status Service
 Regular  Army
 Reserve  Navy
 Active Duty  Air Force
 Retired  Marines Corps
 Former Officer  Coast Guard
 National Guard  Public Health Services
 Surviving Spouse (1)  NOAA
Annual chapter dues are $8.00 per year and cover a period from July through June SELECT OPTIONS
Dues are $4.00 if paid by New Member after 1 January. 1 year $8.00______
(Auxiliary member annual dues are $4.00 per year.) 3 years $24.00_____
5 years $40.00_____
Voluntary Scholarship Contribution (Widows and widowers of deceased eligible member)
TOTAL_______
PLEASE RETURN THIS FORM WITH YOUR DUES CHECK
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NAMETAG APPLICATION

SOUTHWEST ILLINOIS CHAPTER OF THE MILITARY OFFICERS’ ASSOCIATION OF AMERICA
MAILING ADDRESS: P.O. BOX 735, O'Fallon, IL 62269
Member’s name as it should appear on the nametag (First)_______________(Last)_____________

Rank _____________ Branch of Service________________  Active  Retired

Spouse’s name as it should appear on nametag (First)_______________(Last)_________________
(Fill in only if you want a spouse nametag)

Submit to address above with check. Member nametags: $15.00; Spouse nametags: $15.00