USS Long Beach Memberships

Last Name	*
First Name	*
Primary Address	*
City	*
State	*
Zip Code +4	*
Alternate Address (Summer)
City
State
Zip Code +4
Spouse
Home Phone
Cell Phone
Work Phone
E-Mail Address
Highest Rank/Rate While Onboard
Highest Rank/Rate Attained
US Navy Retired		Yes No
US Marine Corps Retired		Yes No
Department
Division
Dates Onboard (Start / End)
Plank Owner		Yes No
What Kind Of Membership Is This?		New Membership Renewal
Membership Length	*	1 Year 2 Year 3 Year
MEMBERSHIP IS JANUARY 1st to DECEMBER 31st EACH YEAR
With a 3 year membership you will receive a license plate holder OR a tie tack OR a hat pin w/ ship seal.
		I DO NOT want a license plate holder I DO NOT want a tie tack or hat pin w/ ship seal
With a 2 year membership you will receive a license plate w/ picture of Long Beach or ship coin w/ case
		I DO NOT want a license plate I DO NOT want a ship coin w/ case