Hampton Roads Chapter MOAA Membership or Renewal Application
Army • Marine Corps • Navy • Air Force • Space Force • Coast Guard • Public Health Service
National Oceanic and Atmospheric Administration

Mail to:
Hampton Roads Chapter MOAA
P.O. Box 4612
Virginia Beach, VA  23454-0612
 
Make checks payable to: HRCMOAA
Select Only One Membership Dues:

Regular
Dues:
1 Year
$20.00
2 Years
$35.00
3 Years
$45.00
Surviving Spouse
Dues:
1 Year
$10.00
2 Years
$17.00
3 Years
$23.00
Only Regular Member pays Annual Dues
Spouse of living Regular Member does
not pay annual dues.

 *  Fields that must be filled in for New Members    Renewing members only fill in name and changes
New, Renewal or Update: 
Date: 

Widow/Widower enter YOUR name and MOAA Number
Name:
     (Last)      (First)      (Middle, or initial)
Grade:
Service:
Component: 
(Ex: USAR, USMCR, USAFR, USNR, ANG, ARNG)
Status:
 Date of Birth: (Month / Day / Year)
Service Dates: 
to
(Month and Year)
(Month and Year)
Retired Date: 
(Month / Day / Year)

Spouse's Name:
   (Last)    (First)    (Middle, or initial)
  Spouse's Date of Birth:  (Month / Day / Year)

E-Mail address: 
Mailing Address:
     (Number and Street)
    (City)      (State)       (9-digit Zipcode)
Home Phone: 
Work Phone: 
Cell Phone: 

Member of National MOAA? 
If Yes, MOAA Number:  Life Member?

Print this page and mail along with your check made payable to HRCMOAA
Enclosed is * $
Signature ___________________________________
04366

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