Academic Award Registration

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  ACADEMIC MEMBERSHIP REGISTRATION

Rank: ____________
First Name: __________________ MI: ____ Last Name:
_______________________

  Dates of Service:
From: _________ To: ______________,          Component: USMC ____,   USMCR ___ ,

  Class Designation: _____________,
Membership Number: ______________
(From
Membership Certificate)

  Current
Address:_________________________________________________________________________
________________________________________________________________________________________

  (Include complete mailing address: Unit, City, State, ZIP and
FPO as appropriate)

  E-mail Address:
__________________________________

  Phone Number:
__________________________________