Membership Application Form       


         Membership Class:  

                   * Required Entries

                   *Last Name:  

     *Formal First Name:      *Informal First:         
                                             (for mailing address)                                             (for the Roster)

                                             (Enter only first name if spouse's last name is same as applicant's.)

            Residence Street:       

                                 City:           State:        Zip:  
                                                                                                                       (xx)                   (xxxxx-xxxx)

                   Home Phone:      Mobile:  
                                             (xxx-xxx-xxxx)                                                 (xxx-xxx-xxxx)


                 Place of Birth:  
                                            (city, state)

                                           (rank, service, # of years)

                   * Required Entry

                                           (school/location, degree, year -- including high school)




                                           (chronological order)

  Emergency Contact(s): 
                                           (name, relationship, phone #)


      SURVEY QUESTION: How did you learn about our Club?      

          Other (Describe):