Return to the Philadelphia Chapter Information Page

Make check payable to:    "USNA AA of Philadelphia"
Mail to:   Jose Mercado, 110 Pin Oak Court, Collegeville, PA 19426
                OR eMail to Treasurer@usnaphil.com

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Source (Alumni/Parent/Other):___________________________________   

Name:____________________________________________________   Class year:___________

Spouse:___________________________________________________

Home Address:_________________________________________________________________

City:_____________________________________________________    State/ZIP:____________

Home #:_______________________________   Work #:_______________________________

Email:________________________________________________________________________

Employer:___________________________________  Position:__________________________

_______ $25 - Full Service Membership

_______ $50 - Blue & Gold Membership (enclose a copy of your business card)

_______ $250 - Tecumseh Club - Full Page Advertisement on the chapter USNA Web page

   N/C        $0 - Dues Paid Parents Club Member (eMail Service)

 

CREDIT CARD PAYMENT
Check one:     (   )VISA      (   )Master Card      (ONLY Visa/MC)

Card #________________________________________    Expiration date________________

Name printed on credit card: _____________________________________________________

Authorized Signature: __________________________________________________________