The National Board of the ROCKS, Inc.
MEMBERSHIP FORM
 
NEW or RENEWAL or ADDRESS CHANGE:  
     
RANK:       RETIRED
FIRST NAME:  
LAST NAME:  
SPECIALTY:  
BRANCH (ARMY, NAVY, AF, MARINE):    
MAILING ADDRESS:    
CITY:    
STATE:    
ZIP CODE:    
HOME PHONE:  
WORK PHONE:  
FAX:  

E-MAIL ADDRESS:  

 
     
 

 OTHER ADDITIONAL INFORMATION.
SPOUSE NAME SOURCE OF COMMISSION  
GRADUATE SCHOOL ATTENDED CLASS YEAR  
MASTER PROGRAM ATTENDED MP CLASS YEAR  
     
  MEMBERSHIP DUES
 
  (Please select one):  
04 & Above - 1 Year ($50) 03 & Below - 1 Year ($30) Regular Life (RL) - ($450)
04 & Above - 2 Years ($96) 03 & Below - 2 Year ($58) Gold Life (GL) - ($650)
04 & Above - 3 Years ($142) 03 & Below - 3 Year ($86) Platinum Life (PL) - ($850)
     
  PAYMENT
     
  Method of Payment: Visa  MasterCard American Express
  Credit Card Number:
  Card Expiration Date: / (mm/yy)
  Card Holder's Name:
  Card Holder's Address:
   

If you agree with all of the information on this form, please press the "Submit" button below to process your renewal application.  Thank you.