Application date: _______________

Name & Rank: _________________________________ Date of birth: ___________________

Active Duty ____

Retired ____

Reserve ____

Former ____

Associate ____

Mailing Address: ____________________________________________________________

City and State: ___________________________________ Nine-Digit Zip Code: ___________

Home Telephone: (_____)__________________ Spouse's Name: ________________________

Occupation: _____________________________________________________

I Served in:

____________ Company/Battery

____________ Battalion

____________ Regiment

From: __________ to: __________

How did you hear about the Association/Sponser: _______eMarine PX_______________

Signature: ___________________________________________

My check for $__________ is enclosed for:

Annual Regular Dues ($30.00) _____	Annual Associate Dues ($30.00) _____
Active Duty Dues ($7.50) _____	*Paid in Full Life Member Dues _____
Installment Payment Life Membership ($40.00 installments) _____

*Life Membership:

Under age 55 = $250

Age 55-64 = $200

Over age 65 = $125

Mail with payment to:
Third Marine Division Association, P.O. Box 254.Chalfont, PA. 18914-0254
Please allow 3-5 weeks for processing and receipt of new membership materials.

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Thank You and Semper Fidelis