NAME:___________________________________RANK/RATE__________

ADDRESS_________________________________DOB:______________

CITY__________________________STATE:_______ZIP+4_____________

SPOUSE:_________________PHONE NO.: ( ___ )____________________

DEPT/DIV.:___________DATE ABOARD:____________TO_____________

EMAIL ADDRESS                 _______________________________________

MEMBERSHIP DUES FOR ONE YEAR (July 1 - June 30)     $25.00_________

MEMBERSHIP DUES FOR THREE YEARS                            $70.00_________

USS GLACIER BASEBALL CAP: (Includes Postage)      $15.00 Ea_________

USS GLACIER DEEPFREEZE PATCH:                               $6.00 Ea_________

USS GLACIER OPERATION DEEPFREEZE (1") PIN:       $5.00 Ea_________
(Similar to the blue DEEPFREEZE patch with the penguin on it)

USS GLACIER ASSOC. WINDOW DECALS (inside):     $3.00 Ea__________

DONATIONS - OPTIONAL - (Postage, Supplies etc.)             _______________

                                                             Total Amount Enclosed: _______________

__________________________

Signature