Date:
___________________________________ New _____ Renewal _____ Name:
__________________________________ Rank/Rate _____________
Address: _______________________________________ Dob ____________
City: _____________________________ State: ____ Zip+4
_______________
Spouse: _________________________ Phone No.: ( ___ )________________
Dept/Div.: _________________ Date Aboard: ___________ To
____________
Email Address: ________________________
| Membership dues for one year (July 1 -
June 30) |
|
$25.00 |
_________ |
| Membership dues for three years |
|
$70.00 |
_________ |
| USS Glacier Baseball Cap: (includes
postage) |
each |
$15.00 |
_________ |
| USS Glacier Deepfreeze Patch |
each |
$6.00 |
_________ |
| USS Glacier Operation Deepfreeze (1")
Pin |
each |
$5.00 |
_________ |
| USS Glacier Association Window Decals
(inside) |
each |
$3.00 |
_________ |
| USS Glacier
Jacket |
each |
$115.00 |
_________ |
| USS Glacier
Painting |
each |
$55.00 |
_________ |
| Donations - Optional - (Postage, Supplies
Etc.) |
|
$ |
_________ |
Total
Amount Enclosed |
|
$ |
_________ |
| _____________________________________
Signature |
|
|
|
| Make checks payable to USS Glacier Assn/Gordon
Wagoner and mail with
this application to: |
|
Mr. Gordon Wagoner
Association Treasurer
4120 Pepperwood Trail
Minnetonka, MN 55305 |
Comments: |
|
|