Name:

Referred By?: (Name & email)

Spouses First Name (Optional)

Address:

City, State, Zip

E-mail Address:

Dates of service:

MOS/TITLE
(example: 05D/Direction Finding)

Duty Stations: (List on back if necessary)

1.
2.
3.
4.

RE-UP  Renewing Membership:

Members renewing for multiple years may choose a complimentary PX item from the list on the right (circle item number)

NASAA patch featuring the "Vigiles Salutis" school crest (3") (item #2)

Round NASAA shoulder patch style window sticker (item #5)  

ASA "LFCF" shoulder patch style window sticker (item #6)

NASAA patch featuring the ASA "LFCF" insignia (3 ")  (Item #1)

PRIVACY SELECTION:

_____ Yes - You may publish my name, e-mail address, and City, State to the NASAA Website

_____ No - Please do not publish my name, e-mail address or City, State to the NASAA Website

_____ Publish My name only on the NASAA Website

_____ Publish my name and e-mail address only on the NASAA Website

Date___________________Signature____________________________
 

(Questions or comments? send e-mail to chui101@yahoo.com or include on back of this form)

Be sure to make checks/money orders payable to NASAA
Print this form and mail, along with a check or money order to:

NASAA, C/O Andrew Rodriguez
265 Tavernier Drive, Ponte Vedre, FL 32081