Member Information

Today's Date   YYYY-MM-DD format (e.g. 2014-01-31)

    Current MOAA National Member?     Member #

Name

Rank     Pay Grade     Service     Status

    If this is a change request, please include both the From and To information.
    If this an initial membership application, simply include the To information.
    Use dash (-) as the separator in all phone numbers.

From

Address

City St. ZIP

Email

Home Phone

Work Phone

Cell Phone

Marital Status

Spouse's Name

Member DOB   YYYY-MM-DD format (e.g. 2014-01-31)

Spouse DOB   YYYY-MM-DD format (e.g. 2014-01-31)

To

Address

City St. ZIP

Email

Home Phone

Work Phone

Cell Phone

Marital Status

Spouse's Name

Member DOB   YYYY-MM-DD format (e.g. 2014-01-31)

Spouse DOB   YYYY-MM-DD format (e.g. 2014-01-31)

 

 

- OR -
print         form

AND

 

 

Mail form to:

  Lt Col John W. Seanor, USAF (Ret)
  49 Emory Court
  Bossier City, LA 71111-8156