MEMBERSHIP APPLICATION
Please mail to:
Mass Benefits Consultants, Inc.
7212 Poplar Street
PO Box 828
Annandale, VA  22003-0828

Last Name _______________________MI _____ First Name ________________________

Street Address_____________________________________________________________

City ___________________________ State _______ Zip Code _____________________

Male _____ Female _______ SSN _______________________ Date of Birth ___________

Office Phone ( ) ____________________ Home Phone ( ) ______________________

E-Mail ______________________________________

Type of Payment:

Option A

___ $10.00 Annual Association Fee for DOI, OPM, OAS employees

___ $12.00 Annual Association Fee for GSA, & other employees

Option B

___ $26.00 IDRA Membership PLUS

Employment:

___ OPM ___ OAS ___ GSA ___ STATE ___ RED CROSS ___Others

DOI employees please check the bureau

___ BIA ___ BLM ___ BOR ___ FWS ___ MMS ___ NBC

___ NPS ___ OIG ___ OS ___ OSM ___ USGS ___ SOL

Other:

Signature _______________________________ Date ____________________________

Office use only:

Member Number ___________ Effective Date ____________________

Action Plan Type __________________ Amount Paid ______________

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