346 Broadway, New York, NY 10013 Rm. 806
Telephone# 212-267-3318 Fax# 212-442-4170
Email Address mpma42@verizon.net
Membership is open to all Veterans and Active Duty members of all branches of the Armed Forces, regardless of race, creed, or natural origin.
Last Name, _________________________First Name, ___________________ MI_____ DOB_____/_____(MM / YY)
Street Address, _________________________________City, __________________, State, ________ Zip,__________
Phone#, ( ) ___________________ Fax, _____________ Email, _____________________
Branch of Svc, _________ Yrs Active Served, 19 / 20___ to 19 / 20___ Yrs Reserve Served, 19/20___ to 19 / 20 ___
Emergency / Alternate Contact: Last Name, ___________________First Name, _______________ Relationship _________
Street Address, ________________________________City, __________________, State, ________ Zip, _________
____ I hereby apply for membership in both the National MPMA and the New York Metropolitan Chapter and enclose $60.00 for a one year membership.
____ I hereby apply for membership in the New York Metropolitan Chapter only and enclose $35.00 for a one year membership.
____ I am on Active / Reserve Duty and hereby apply for membership in both the National MPMA and the New York Metropolitan Chapter and enclose $45.00 for a one year membership ($25.00 applied to National & $20.00 applied to NY Chapter Dues).
I Certify that I have been a member of the United States Armed Forces for more than 90 days, and I have received a honorable discharge at the time of my separation from duty. By signing and notarizing this application, I agree to provide proof of my discharge upon request.
Applicant Signature: ______________________________ Date ___________________
Please indicate a check next to the committee's you intend to be serve on as an active member.
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