Mississippi Coast Military Officers Association

Please type or print. Information may be shared with other MCMOA members.

NAME:________________________________________

SPOUSE:____________________________________

RANK/GRADE:________________

SERVICE (CIRCLE): Army, Navy, Air Force, Marine Corps, Coast Guard, NOAA and Public Health Service

COMPONENT (CIRCLE): REGULAR, RESERVE, GUARD, OTHER__________

STATUS: ACTIVE DUTY____ RETIRED____OTHER______

MAILING ADDRESS:_______________________________

CITY__________________STATE:____ ZIP_____________

PHONE:________________________

EMAIL:____________________________________

MEMBERSHIP CLASS: REGULAR or AUXILIARY

NATIONAL MOAA MEMBER? If YES, #________________________ (If known)

SIGNATURE:______________________________________

..............................................................................................................................................

OFFICE USE: Ck#_________ AMT:_________DB_____

PRINTER_______NL_______DIR________OTHER_____

REFERRED BY:_____________________________

NOTE: Widows desiring to be listed in the membership directory with their husband's name, fill out the name section accordingly. i.e. Mrs. Doe, John Thomas. Show your given name in the spouse space. Show the grade and service of your spouse in the appropriate spaces.

MAKE CHECKS payable to MCMOA and mail with application:

MCMOA, ATTN: LCDR DICK ROBINSON, USN. P.O. BOX 5027, KEESLER STATION, BILOXI, MS 39534-0027