| First Name: |
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Middle Initial:
Last Name:
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| Gender: |
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| Email: |
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| Create Password: |
* Re-Enter Password:* |
| Phone: |
(xxx) xxx-xxxx |
| Birthday: |
* mm/dd/yyyy |
| Social Security #: |
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| Please fill in your Preferred Mailing Address: |
| Address Line 1: |
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This is a U.S. address (including APO and FPO) |
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| City: |
* State:*Zip Code:* |
| Country: |
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| Please fill in your Home of Record (Billing Address): |
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| Address Line 1: |
*
This is a U.S. address (including APO and FPO) |
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| City: |
* State:*Zip Code:* |
| Country: |
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| How Did You Hear About Us: |
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| Choose a Campaign: |
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Other: |
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| Service Information: |
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| Current Status: |
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| Branch: |
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| Qualifying Experience: |
*CTRL + Click to select multiple |
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NOTE: You must enter Period Covered if Imminent Danger/Hostile Fire Pay or SSBN is used as sole qualifying experience. |
| Period Covered From: |
mm/dd/yyyy (Required for applicants with no other reported qualifying service) |
| Period Covered To: |
mm/dd/yyyy (Required for applicants with no other reported qualifying service) |
| I would like to join as a: |
Annual Member
Life Member
Installment Life Member - 12 month term
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Any applicant whose 31st, 41st, 51st, 61st, 71st or 81st birthday will occur after the date of application and on or before December 31st of the current calendar year, shall pay only the fee that would be required on his next birthday. |
| Payment Information (uses Billing Address): |
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Once you submit your information, we will authorize payment using the credit card information you provide, and we will review your application to determine eligibility. You will be emailed with the results within 2-3 business days. If your application is accepted, we will process your membership and your credit card, and a membership card will be mailed. If your application is rejected we will not process your credit card, and the authorization will fall off of your credit card account within 7-10 business days. You will not be refunded if it is determined you willingly submitted fraudulent information as a part of your application. |
| Attestation of Eligibility: |
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Address:
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City, State, Zip:
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Address:
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City, State, Zip:
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| ** Address validation could take up to 1 (one) minute to complete after you click "Submit". Do not click "refresh" or use the "back button" before the validation process has completed. ** |
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