MEMBERSHIP APPLICATION AND DATA FORM

CURRENT CIVILIAN STATUS:

E-mail Address: ___________________

Last Name, First, MI: _________________________________ Phone: (____)___________

Street: _____________________________________________ County: ________________

City: _______________________________ State: __________ Zip: ___________________

CURRENT MILITARY STATUS:

Rank: ____________ Retirement Date: _______

Unit of Assignment: ____________________________________ Position: _____________
(If currently assigned to 100th Division (IT))

Last 100th Division Unit: ________________________________ Position: ______________
(If not assigned to 100th Division (IT) or if retired)

Termination Date: _______

AGREEMENTS:

I submit the above data for the reason checked below:

To apply for a Regular Membership ( ) New ( ) Renewal:
Enclosed are $15 annual dues.

To apply for a Life Membership ( ) New ( ) Renewal:

$160 Lifetime Dues (Payable in full amount).
$160 Lifetime Dues (Payable in four annual payments of $40 each)

To apply for Associate Membership ( ) New ( ) Renewal:

Enclosed is $15 for Associate Annual Dues.
Enclosed is $160 for Associate Life Membership (Payable in full amount).
Enclosed is $160 for Associate Life Membership (Payable in four annual payments of $40 each).

I will promote the Association of the Century and will comply with its By-Laws.

I hereby authorize my signature, membership and authentication, dates and everything about them to be reproduced and disseminated to all members of the Association and to others, as they deem appropriate.

Signature: ____________________________________________________ Date: ___________________________

All Life Membership funds are invested. Only the yields of such investments are used for supporting the various activities of the Association of the Century. When you pay for a Life Membership, you leave a legacy for the future support of the 100th Division (IT)

Annual Membership dues is not prorated and is due on January 1st each year.

Rev 08/04