Please do NOT try to fill in this page, it is not an internet form!
Make check marks, fill in the blanks, or circle please
Is your application as a new member______or are you renewing_______?
Last Name_______________First Name______________Middle Initial_____________
Grade/Title_____________Suffix____
Service: Army_____Navy_____Air Force_____Marines_____National Guard______
Coast Guard______NOAA_____USPHS_____Reserve______
Mailing address_______________________________________
City____________________State__________Zip____________
Telephone_____ _____ _______Email____________________________________________
Member of MOAA yes_____ no_____MOAA number_____________
(You can get your MOAA membership number off the magazine label).
(First year membership free if joining VIPMOAA)
If you are an auxillary member please list your sponsor's
Name____________________________________grade_______service______
How do you want to be involved in your local chapter of MOAA?
Are you interested in serving on the Board? ____ Please circle your interest. President, VP, Secretary, Treasurer
Are you interested in serving on a committee? ___ Please circle your interests. Hospitality/Meeting arrangements,
Membership/Recruiting, ROTC Awards Communications: Newsletter, Web, Email,
Legislative, Personal Affairs, Chaplain, State Council, Retirement Community Liaison
New members are invited to provide a short bio for our chapter newsletter
Date of submission_________Dollar amount__________Signature___________________________________
RENEWAL/NEW DUES ARE $15.00, AUXILLARY MEMBERS $10.00
NEW MEMBERS JOINING AFTER APRIL 1ST PAY PART YEAR RATE, $12.00 AUXILLARY $8.00
Mail to:
VIPMOAA Membership, P. O. Box 4305, Ft. Eustis, Va. 23604-0305
