E1-E6 AUSN Membership Application

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Tuesday, May 22, 2012

E1-E6 Membership Application

Website Account Information

Username:

Password:

Confirm Password:

Display Name:

Email Address:

Contact Information

Rate/Rank:

First Name:

Please enter a value for the field Middle Name.

Middle Name/Initial:

Last Name:

Suffix:

Street:

Unit:

City:

State:

Postal Code:

Telephone:

Cellular Phone:

Work phone:

Additional Information

Date of Birth:*

Please enter a value for the field Last 4 Digits of your SSN.

Last 4 digits of SSN:*

Paygrade:

Designator:

Membership Fee

Membership Fee:

$30 for 1 year
$50 for 2 years
$75 for 3 years - best value!

Billing Information

First Name on Card:

Last Name on Card:

Credit Card Type:

Visa
MasterCard
American Express
Discover

Credit Card Number:*

Expiration Date:

Security Code:

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