Primary Personal Information

*First Name

Middle Name

*Last Name

*Rank

*Component

*War Veteran

*War Period

*Date of Birth

*Gender

*Email Address

*Phone Number

Recruiter ID

Recruiter Chapter #

*Address

*City

*State

*Zip Code

Spouses Name

*Number of Dependents

Expected Graduation Date

Next Base Assignment

Member Chapter Assignment

*Membership Type

*Membership Term

Remarks

Joint Member's Personal Information

Address for Joint applicant same as Primary applicant

*First Name

Middle Name

*Last Name

*Rank

*Component

*War Veteran

*War Period

*Date of Birth

*Gender

*Email Address

*Phone Number

Recruiter ID

Recruiter Chapter #

*Address

*City

*State

*Zip Code

Spouses Name

*Number of Dependents

Expected Graduation Date

Next Base Assignment

Member Chapter Assignment

*Membership Type

*Membership Term

Remarks

Primary Member's Billing Information

*Credit Card Number

AMEX enter '0' before card number

*Name on Card

*Expiration Date

*Security Code

Visa/MC/Disc enter '0xxx' AMEX enter 'xxxx'

Campaign Code

19JM50

*Auto Renew

Billing address same as personal address

*Billing Address

*Billing City

*Billing State

*Billing Zip Code

Optional Joint Member's Billing Information

Credit Card Number

AMEX enter '0' before card number

Name on Card

Expiration Date

Security Code

Visa/MC/Disc enter '0xxx' AMEX enter 'xxxx'

Auto Renew

Billing address same as personal address

Billing Address

Billing City

Billing State

Billing Zip Code

Electronic Signature

Type your name to electronically sign the form.

*Signature