MILITARY EX SIGNUP FORM

Full Name : Address: : City : Country : State : Zip : Telephone: Cellular : Residence : Office : Message Phone : Email Address : Verify Email Address : Sex : Select Male Female Occupation : Please Select Employed Student Retired Position : Education : Please Select No Formal Education High School Drop Out GED Some College No College Bachelor's Degree Graduate Degree Professional Degree Annual Income : Please Select No Income Under 25k Annual 25k to 35k Annual 35k to 45k Annual 45k to 55k Annual 55k to 65k Annual 65k to 75k Annual 75k to 85k Annual 85k to 95k Annual 95k to 100k + 150k to 250k 150k to 250k 250k+

Active Duty Military Rank : Rate : Years of Service : Month / Year Service Begin : Retired Military Rank : Rate : Year You Retired : Reservist Rank : Rate : DOD Civilian Prior Military Type of Discharge (Please check all that apply): Medical General Bad Conduct Other Than

Honorable If Discharged Other Than Honorable, Please Tell Us Why You Were Discharged: Civilian Dependent Spouse Dependent Child Military Family Member How Are You Related To The Military (Please List Your Relation) Ex Spouse of Military Member US Citizen Foreign National Friend Offshore Friend In America Interested In: Being A MILITARY EX MEMBER Making A Donation to MILITARY EX Making a Sizable Donation to MILITARY EX Having Your Issue or Grievance or Problem Addressed Submitting A Nomination for the Military EX KISS OFF AWARD Submitting A Nomination for the Military EX KISS KISS KUDOS AWARD Anonymously Submitting A Problem To The MILITARY EX WATCH LIST Becoming A MILITARY EX OPERATIVE Becoming A MILITARY EX VOLUNTEER Becoming A MILITARY EX SPONSOR Becoming A MILITARY EX MEDIA PARTNER Telling Your Story To MILITARY EX Being Interviewed On MILITARY EX TV Being Interviewed ON MILITARY EX RADIO Participating In A MILITARY EX ACTION CAMPAIGN Participating In A MILITARY EX CONTEST Commenting or Offering A Suggestion Comment Box: