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 ___________________________________
04375
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