Membership Application - Commissioned Officers Association of the

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Membership Application - Commissioned Officers Association of the
APPLICATION FOR NEW MEMBERS ONLY
8201 Corporate Drive, Suite 200, Landover, MD 20785
301-731-9080/301-731-9084 (fax)
www.coausphs.org
Previous/Current members, please visit www.coausphs.org to renew
membership dues and update personal profile via the Members Only site.
*Last Name:
*First Name, MI:
*PHS Grade/Rank:
CATEGORY
*Address
ACTIVE DUTY STATUS
*City
* State
*Zip Code
*Country
* Birthdate (MM-DD-YYYY)
*Day Phone
* Active Duty Date (MM-DD-YYYY)
Retirement Date (MM-DD-YYYY)
*E-mail Address
PLACE AN "X" NEXT TO APPLICABLE NATIONAL DUES AMOUNT....
ACTIVE - Grade 03 & Below
$85.00
ACTIVE - Grade 04 & Above
$140.00
RETIRED -Grade 03 & Below
Age 64 & Under
$85.00
RETIRED - Grade 04 & Above
Age 64 & Under
RETIRED - Age 65 & Above
$140.00
$85.00
CO-STEP
$30.00
STUDENT
$30.00
FORMER COMMISSIONED OFFICER
$55.00
ASSOCIATE/Civilian Member
$55.00
******IMPORTANT******
MEMBER DUES INFORMATION - COA INVOICES DUES ON A FISCAL YEAR,
JULY 1 THRU JUNE 30. COA DOES NOT
PRO-RATE MEMBER DUES.
TOTAL NATIONAL DUES
BRANCH/ LOCAL DUES
PLEASE ADD MY
DONATION
*TOTAL
ENCLOSED
- Frontline is available to COA Members @
https://members.coausphs.org/secure/default.aspx
*Total payment must reflect both National and local dues, if affiliating with a local branch.
PAYMENT OPTIONS: (SELECT ONLY ONE OPTION)
If selecting payment by check, please print a copy of the application and include with payment.
Check enclosed, made payable to COA.
I authorize COA to charge the selected card for the total noted above.
DISC
Card Number :
MC
VISA
T
e
Expiration Date:
a
Signature:
T
e
Submit by E-mail
LIFE MEMBERSHIP
Age
Dues Amount
39 & Under
40-44
45-49
50-54
55-59
60-64
65-70
71 & Above
$1,805
$1,645
$1,470
$1,265
$1,045
$ 805
$ 605
$ 495
Applicable Dues
Payment may be made in full or in three installments within COA's current fiscal year.
If affiliating with a local branch, applicable dues are invoiced yearly.
COA does not pro-rate annual National dues or Life Member dues.

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