Completion Tracker:
 

I hereby apply for membership in the Uniformed Services Benefit Association. I am eligible for such membership and the statements I have made are true and complete. I am: an Active Duty Serviceperson scheduled for discharge within the next 18 months; under age 60; not a resident of OR or TX and; applying for USBA Membership. I agree that I be provided with $5,000 of Accidental Death & Dismemberment (AD&D) coverage under USBA Group Policy G-5393-0. I understand that the cost for the first 12 months of this coverage will be paid for by USBA. I also understand that my membership is subject to USBA’s approval.

First Name: * 		 
Middle Initial:  
Last Name: *  
Gender: *  
Birth Date:  *    /   / 
SSN: (XXX-XX-XXXX)  *  
Home Phone:  
Work Phone (optional):       Ext.
Address: *  
City: *  
State:  *      ZIP:
E-mail Address:  *  
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Duty Status: *

Service Branch:  *


(Military Personnel Only)

Rank:  *
(Military Personnel Only)
Actual (or estimated) date of separation
or retirement:
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Years of Service  *
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