ADAA LIFETIME MEMBERSHIP APPLICATION
$50.00 (PRICES SUBJECT TO CHANGE)
APPLICANT INFORMATION
Name (First, Middle, Last):
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Mailing address (for membership materials): Click here to enter text.
City: Click here to enter text.
State: Click here to enter text.
Email: Click here to enter text.
ZIP Code: Click here to enter text.
Phone: Click here to enter text.
MILITARY INFORMATION
Current Unit: Click here to enter text.
Rank:
Duty Station: Click here to enter text.
Military Status: ☐ Active
☐ Retired
☐ Civilian ☐ Family
AWARD NOMINEES
Nominating Brigade: Click here to enter text.
Unit POC for nominations: Click here to enter text.
PAYMENT
*To pay by Check or Money Order please send this form with payment to:
ADAA
PO Box 33727
Ft. Sill, OK. 73503
Credit Card Payment (do not fill out if: applying in person or paying online at http://mkt.com/ada-association)
Name:
Card Holder Info:
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Billing Address:
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City, State, Zip:
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Email:
Authorization Amount $ Click here to enter text.
MasterCard ☐ Visa ☐ AMEX ☐Discover ☐
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Card # Click here to enter text.
Billing Zip Code: Click here to enter text.
Exp. Date: Click here to enter text.
CVV2 (3 digit # on back of Visa/Mc, 4 digits # on front of AMEX) Click here to enter text.
I authorize the ADAA to charge the credit card indicated in this authorization form according to the terms outlined above. I certify that I am an authorized user of this
credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Card Holders Signature/Date
_________________________________
ASSOCIATION USE ONLY
Member Number:
Date:
Revised 1/30/17