Title: UNITED STATES ARMY WARRANT OFFICERS ASSOCIATION
Author: Gary Nisker
Last saved by: mine
Company: USAWOA

United States Army Warrant Officers Association

462 Herndon Parkway, Suite 207, Herndon, VA 20170-5235
1-800-587-2962, 703-742-7727, Fax 703-742-7728, Web: www.usawoa.org, Email: usawoamdb@verizon.net

GENERAL PURPOSE MEMBERSHIP FORM

Place "X" in appropriate box  [   ] New   [   ] Rejoin   [   ] Renew   [   ] Data Change   [   ] Chapter Affiliation

MEMBERSHIP DATABASE INFORMATION - (Press INSERT key & type between square brackets) (See “release” option below)

Social Security or Member # : [                                                   ]   Rank: [          ]   Branch/MOS: [___     _______   ]
(Last 5 digits of SSN required for use in your member number. SSN is not released to anyone for any purpose)

Name [                              _______________________________]   Pay Entry Basic Date (mm/dd/yyyy) [ __  _  __    ]

Address  [                                                                                                           Date Birth (mm/dd/yyyy) [         ___    ]

City  [                                                                      ]   State [    ]   ZIP+4 [             __  ]   Home Phone [                        ]

Work Tel * [                             __________]      (*DSN for OCONUS work phones otherwise commercial)

Spouse (First Name) [                                 _    ]   Highest USAWOA Office held [                                                          ]

E-Mail Addresses *  [                                                                                                                                                     ]
                                  (* AKO – us.army.mil preferred) (If both military and civilian are used, place preferred one first)

RELEASE OF INFORMATION: (Place "X" in appropriate box):   I [   ]  DO  [   ]  DO NOT want the above information released. 
(Regardless of option checked, no information is released outside of USAWOA.

CURRENT STATUS (Place "X" in appropriate box) (*AGR please check ARNG or USAR)
[   ] Active Army - [   ] ARNG* - [   ] USAR* - [   ] Retired - [   ] Former Warrant Officer - [   ] Associate 

CERTIFICATIONS (Place "X" in appropriate box)
I [   ] HOLD / [   ] HAVE HELD a Warrant issued to me by the Secretary of the Army (If NO check Associate above)
I [   ] AM / [   ] AM NOT entitled to wear the National Defense Medal

TERM OF MEMBERSHIP(Check only one dues category please) (Effective 1 January 2011 the NEWSLINER will be delivered electronically. If you wish a paper copy there will be an additional cost of $12.00 per year.)

[__] INITIAL ONE-YEAR MEMBERSHIP FOR WO1s ONLY AT NO COST     [__] with paper copy of NEWSLINER by mail $12

MEMBERS DUES with electronic delivery of NEWSLINER | MEMBERS DUES with paper copy of the NEWSLINER (Note 1)
Regular/Assoc.  [   ] 1 Yr $45   [   ] 3 Yrs $126   [   ] 5 Yrs $200 | Regular/Assoc.  [   ] 1 Yr $57   [   ] 3 Yrs $162   [   ] 5 Yrs $260
Retired  [   ] 1 Yr $30   [   ] 3 Yrs $84   [   ] 5 Yrs $$130 | Retired   [__] 1 Yr $42   [__] 3 Yrs $120   [   ] 5 Yrs $190

LIFE MEMBERSHIPS also available, contact USAWOA at 1-800-589-2962 or visit www.usawoa.org/LM_Facts.htm.
Note 1: Life Memberships with both electronic and paper NEWSLINER via mail start as low as $260.

 [   ] Check or Money Order for membership dues is enclosed. 
 [   ] Charge my: [   ] VISA,  [   ] MC,  [   ] Discover,  [   ] AMEX - # [                                            __   ]  Expires [ _   / __  ]
	(No DEBIT cards, please)

CHAPTER AFFILIATION (Check one)
 [   ]  Please affiliate me with a chapter near my home.
 [   ]  Affiliate me with the [                                                                                                                                 ] Chapter
 [   ]  Please DO NOT affiliate me with a specific chapter.

Applicant's Signature and Date  [                                    _                ] (Typed full name and date if submitted by email)

Optional Sponsor (rank & name of sponsor or name of sponsoring chapter)  [______________________________________]

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PURPOSE: To maintain organizational records.  Used by national, region, and chapter officers, office staff and members (when approved) to generate mailing lists, chapter and region rosters, etc.  Failure to furnish information may result in members not receiving the NEWSLINER, ballots, letters and other correspondence of importance to the membership.  Incorrect information may result in erroneous computation of statistical & financial reports and/or credit for prior membership.

[ Click here to send the completed form to a secure email account at the Home Office ]
(If clicking on the above link does not bring up your email program please open your email 
and then manually address an email note to <herb.rundgren@us.army.mil>)
IN EITHER CASE DO NOT forget to ATTACH the completed form to the email

USAWOA Form 600-1F (Fill-in) (Revised January 2011)