E & A A Membership Application

(Membership categories changed as of August 25, 2006. Annual memberships are valid from

August 25 through August 24of the following year)

NAME:_______________________________________________________________

SPOUSE NAME: _______________________________________________________

LIST SPOUSE IN DIRECTORY: YES: ______ NO: ______

ADDRESS:____________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

LIST ADDRESS IN DIRECTORY: YES: ______ NO: ______

HOME PHONE: ________________________________

LIST PHONE IN DIRECTORY: YES: ______ NO: ______

EMAIL ADDRESS: ____________________________________________________

LIST EMAIL IN DIRECTORY: YES: ______ NO: ______

PARK OR OFFICE WHERE YOU: WORK: ___________ RETIRED FROM:________

_______________________________________________

_______________________________________________

TITLE: _______________________________

YEARS WITH THE NPS: _________________________

YEAR RETIRED: __________________________

LIST EMPLOYMENT INFORMATION IN THE DIRECTORY: YES: _____ NO: _____

TYPE OF MEMBERSHIP: Date: _______________________________

VOLUNTEER ANNUAL: ($35) __________

Annual membership open to those who have served at least 500 hours to the NPS

NPS ANNUAL: Single ($30): _______ w/spouse ($50) _______

NPS LIFE: Single ($350): _______ w/spouse ($500) ________

ASSOCIATE INDIVIDUAL ANNUAL ($40) _______ LIFE ($400) _________

An individual membership open to those interested in advancing the purposes of E&AA

ASSOCIATE CORPORATE ANNUAL ($500) ________

Open to not-for-profit and for-profit organizations interested in advancing the purposes of E&AA

MAKE PAYMENTS TO:

EMPLOYEES & ALUMNI ASSOCIATION
EASTERN NATIONAL
470 MARYLAND DR. SUITE 1
FT. WASHINGTON, PA 19034