Print clearly! Date________________________
Full name__________________________________________________
Rank/Title__________________ Widow(er)
Service (CIRCLE ONE): USA USN USAF USMC USCG USPHS NOAA
Spouse's Name________________________________________
Spouse's Rank/Title__________
Address___________________________________________________
City State_____________________________ Zip + 4 _______________
Telephone_______________________ Birth date__________________
Email address__________________@___________________________
Year entered service______________
Year retired or discharged_______________
Year arrived in Gainesville______________
SSAN__________________________________________
National MOAA Membership Number __________________________ (From your membership card or above your name on the mailing label of The Retired Officer Magazine)
If not retired, business or occupation ______________________________
Hobbies___________________________________________________
Spouse's hobbies______________________________________________
List up to three units you served in
____________________________________________________________
____________________________________________________________
____________________________________________________________
The chapter relies on volunteers to function. Please indicate if you can help in the following areas:
Chapter Leadership Position (officer, board of directors)
Committee assignment
Luncheon/Dinner meeting programs
Newsletter articles
Any area where I can help
NEW MEMBER: Fill in entire form. Enclose $12 dues. Dues received after 1 Oct will apply for the next year. Dues are due for all memberships on 1 Jan. No dues for spouses, honorary, or widow(er) members.
WIDOW(ER)S: Check the box and fill in the entire form using your own name, SSAN, and address. Show your title (e.g. MRS or MR). Show deceased spouse's name, rank, and service. There are no dues.
RENEWALS: Use the certificate sent to you in the fall. Please DO NOT use this form.
Signature _______________________________________________