Personal Information Date:___________
(Last Name) (First Name, MI) (Spouse Name)  
(City) (ST) (ZIP +4)    
(Home Phone) (Work Phone - Optional)  
(Mobile Phone)          
(E-Mail Address) (Web Site) (Birth Date)    
Division Rank/Rate Mo and Yr Plank Ownner    
Service Retired Age Highest Rank    
LIFE Membership is based on your age and is:  
AGE GROUP FEE 40 to 44 $210 60 to 64 $120
29 and Younger $295 45 to 49 $180 65 to 69 $105
30 to 34 $265  50 to 54 $160  70 to 74 $80
35 to 39 $235 55 to 59 $140 75 and older $50
NOTE: 1.  You may pay the full life membership fee in one payment or in ten equal monthly installments.  If you prefer to pay monthly, you should send an initial installment of one tenth of the total fee for your age group with this application.  We will enter your life membership and send you your membership card.  You will be expected to forward balance of monthly payments. in a timely manner.  Your certificate will be forwarded upon receipt of final payment.  In the event a member paying on the installment plan finds that he can not continue to make monthly payments, all monies previously paid will be credited to paid up annual dues, currently $10.00.
NOTE 2.  Any dues currently paid in advance may be applied to reduce the  fee for your age grroup
NOTE 3.  Please return to Dave Brandt, Secretary, USS SAMPSON ASSOCIATION,   1 Ridge Lake Drive,  Manning SC 29102-9512