STARFLEET COMMAND HQ PR QUADRANT
MEMBERSHIP APPLICATION
APPLICANT INFORMATION
(Please copy this application or email to us thank you)  

Name:______________________________________________________________
Date of birth:_______________Membership # :_______Phone:________________
Current address:_____________________________________________________
City:______________________State:_______________ZIP Code:____________

EMPLOYMENT INFORMATION
Current employer:___________________________________________________
Employer address:____________________________________How long?_______
Phone:_________________E-mail:_______________________Fax:____________
City:___________________State:________ZIP Code:_______________________

EMERGENCY CONTACT
Name of a relative not residing with you:__________________________________
Address:_____________________________________________Phone:__________
City:___________________State:________ZIP Code:_______________________
Relationship:_____________

SPOUSE INFORMATION IF JOINT MEMBERSHIP
Name:______________________________________________________________
Date of birth:____________Membership # :________Phone:__________________

SPOUSE EMPLOYMENT INFORMATION
Employer address:____________________________________How long?_______
Phone:_________________E-mail:_______________________Fax:____________
City:___________________State:________ZIP Code:_______________________

CHILDREN IF MEMBERSHIP PRIVILEGES DESIRED
Name:____________________Name:___________________
Name:____________________Name:___________________
SIGNATURES

I authorize the verification of the information provided on this form as to my credit and employment. I have made a copy of this application.

Membership dues is $25, $10 for each additional family member,
Children under 10 free. Membership dues ages 14 - 18 yrs $15; Ages 11 - 13 yrs : $8.

Signature of applicant:__________________________Date:__________________
Signature of spouse: __________________________________________________
(only if for a joint membership): Date:___________________________________

A return mail or email copy of this application will be sent to you soon.

You may contact Capt. George Mustafa at 787-525-0923,
email: mustafa56@msn.com or Flt. Admiral Richard Giordano at 787-448-2053
email: giordano@prtc.net .

The Federation Society
MX-25, Calle 434 & Iturregui Ave. Carolina, Puerto Rico 00982