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Contact Us

5436 Peru St. #1
Plattsburgh, NY 12901

800.424.2969
518.563.9479
Fax: 518.324.5204
info@amra1973.org

Membership Form

Membership Invitation

Membership is effective on the date application is approved and processed at AMRA.

AMRA cannot process your application until you have completed the payment section and provided proof of eligibility. You will find information as to what constitutes proof within the application below.

1 Surviving spouse should apply for membership in his/her own name, not in the deceased spouse's name.

* Designates required field.

*Type of Membership: All prices are in U.S. funds.

I prefer to receive future renewal notices by

*Eligibility: Membership must be in Military Member's Name unless applicant is their surviving spouse.1


*First Name:



MI



*Last Name:


*International:

*Mailing Address:


*City:



*State (Choose INT for International):



*Zip/Postal Code:



*County:



*Country:



*Year of Birth:
(yyyy)


*Spouse's Name:
(type none for no spouse)


*Phone #:
Include area code xxx-xxx-xxxx


*Primary Email Address:



Secondary Email Address:

*Combat Vet

*Branch RETIRED From:

Nearest military installation:


*Proof of Eligibility: Proof of eligibility must accompany application. Select ONE from the list below (redact or blackout Social Security numbers) and submit to National Headquarters.


RETIRED:
RETIREMENT DD214
RETIREMENT ORDERS OR CERTIFICATE
MILITARY RETIREE ID (copy of front and back)
MEDICAL RETIREMENT DOCUMENT

DISABLED:
DISABILITY RATING DOCUMENT INDICATING DISABLED, T & P

SURVIVING SPOUSE:
DIC DOCUMENTS or CHAMPVA ID CARD OR MILITARY ID (copy front and back)

*I will send my proof of eligibility via:
Direct Upload Max file size 2MB.
U. S. Mail
Fax to 518-324-5204
Email to info@amra1973.org

*Chapter Affiliation:


Do you wish to receive the full color, online quarterly newspaper?


* How did you hear about us?


*TRICARE/CHAMPVA supplemental insurance with Selman Co.?

Optional - for statistical purposes only

Career service dates from (Year only) to .

Rank at Retirement:



Skills/Expertise:


Hobbies and Interests:


Recruited by: (Member Name and Member #, if available)


Comments:
(255 max characters)


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I do not wish to receive vendor offers.




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