INTERIOR DEPARTMENT MEMBERSHIP APPLICATION 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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