PORTSMOUTH AREA CHAPTER (PACMOAA)
AN AFFILIATE OF THE
MILITARY OFFICERS ASSOCIATION OF AMERICA
(MOAA)
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MEMBERSHIP APPLICATION
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Name in full:
(Please print) Surname: ___________________________________________ ________First: ____________________________ MI: _______
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Rank________________ Service: _________________ Birth date (MM/DD/YY): ______________________
Status: [ ] Active [ ] Retired [ ] Former
[ ] Reserve [ ] National Guard [ ] Auxiliary (Surviving spouse of eligible officer)
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Address: Street: __________________________ City: ___________________ State: _____ Zip: _________
Home telephone: ___________________________ E-mail address: _________________________________
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Civilian Occupation: ______________ MOAA Membership No. _________________ Nickname___________
Spouse's Name _______________________ Spouse's Nickname ___________________________________
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Applicant's signature: ______________________________________________Date: __________________
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Are you willing to serve as a board member or on one of our committees ? [ ] Yes [ ] No
Annual dues are $20* for regular members and $15* for auxiliary members. Make check payable to PACMOAA
and mail to:
PACMOAA, PO Box 5353, Portsmouth, VA 23703
*NOTE: For those first joining after July 1: $10.00 or $7.50, as applicable.
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