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Highway Mariner Membership Application Form

Last Name:
  
Applicant, First Name:
  
Spouse, First Name:
  
Address:
  
City:
   State: Zip:
Home Squadron:
   District:
Rank held in USPS
  
Phone Numbers:
(H) Cell:  
Email Address:
  
Signature:
  

Mail completed application and dues payment of $8.50 to:

Pegy Miller
1415 N. 55th Street
Grove, OK  74344

Make checks payable to Pegy Miller
Note in memo field for "Highway Mariners Dues"

                   Revised 3-2-2007