Chapter Membership or Renewal Application
Army -- Navy -- Air Force -- Marine Corps -- Coast Guard -- Public Health Service
National Oceanic and Atmospheric Administration
Mail to:
 
Hampton Roads Chapter MOAA
P.O. Box 4612
Virginia Beach, VA  23454-0612
 
Make checks payable to: HRCMOAA
Membership Dues:
Regular Dues:
1 Year $15.00
2 Years $28.00
3 Years $39.00
 
Auxiliary Dues:
1 Year   $7.50
2 Years $14.50
3 Years $21.00
 *  Fields that must be filled in
New or Renewal:  * 
Date: 
Name: * ,  * 
     (Last)
(First)
(Middle, or initial)
** Widow enter YOUR name, SSN, and MOAA Number;  spousal info in other blocks
Widow(er) Name:** , 
     (Last)
(First)
(Middle, or initial)
Grade: * 
Service:* 
Status: * 
Active - Retired
Widow - Widower
Former Officer
 
Date of Birth: *  (Month / Day / Year)  
Spouse's Name: , 
   (Last)
(First)
(Middle, or initial)
Mailing Address:
* 
     (Number and Street)
*  *  * 
    (City)      (State)       (9-digit Zipcode)
Home Phone: * 
Work Phone: 
Service Dates: 
to
(Month and Year)
(Month and Year)
Retired Date: 
(Month / Day / Year)
Member of National MOAA?  * (Yes or No)
If Yes, MOAA Number:  Life Member? (Yes or No)
E-Mail address: 
Print this page and mail along with your check made payable to HRCMOAA
Enclosed is * $
Signature ___________________________________
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All information contained in this website is the exclusive property of Hampton Roads Chapter MOAA (HRCMOAA) © 2008