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Username*

First Name*

Last Name*

E-mail Address*

Password*

Confirm Password*

Elected Membership Category*

Single MembershipFamily Membership

Name of Spouse if elected for a Family Membership

Is your spouse currently a member?

YesNo

Is this application for a new applicant or for a reactivated applicant*

New ApplicationReactivation

Mailing Address*

Apt/Unit

City & State*

Zip/Postal Code*

Telephone Number*

Other Number(s)

Name, Village & Autonomous Community of Living Parents

Village & Autonomous Community of living parents

How many dependent children under 21 years or dependent children who are full time students under 25 years.

Child name

Name & phone number of primary beneficiary*

Address of primary beneficiary*

Zip/Postal Code of primary beneficiary

Name, Address & Phone number of Contingent Beneficiary

Name, Address & Phone number of emergency contact person

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