MEMBERSHIP APPLICATION AND DATA FORM

Civilian Status:
	Name:	Last: First: MI: Suffix:
	Street Address:
	City:	State: Zip:
	E-Mail:
	Home Phone:	()-
	Work Phone:	()-
	Fax Phone:	()-
	Spouse's Name:

Military Status:

Rank:

Retirement Date:

If currently assigned to 100th Division (IT) or any active unit:

Unit of Assignment:

Position:

If not currently assigned to 100th Division (IT) or if retired

Last 100th Division
Unit of Assignment:

Position:

Termination Date:

Membership Info:

Type of Membership:

If renewal, enter Membership #:

Annual

Annual dues are $15 per year.

Lifetime

Lifetime membership costs $160 and can be paid in full, or in 4 annual installments of $40.

Associate Annual

Annual dues are $15 per year.

Associate Lifetime

Lifetime membership costs $160 and can be paid in full, or in 4 annual installments of $40.

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)

Agreement:

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.

By clicking here, I indicate my acceptance of this agreement.

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

MEMBERSHIP APPLICATION AND DATA FORM

Civilian Status:

Military Status:

Membership Info:

Agreement:

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