Form Mltrc1001ge - Group Tricare Prime Supplement Plan Enrollment Form Page 3
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3OFFICE USE ONLY
RAUS MEMBERSHIP APPLICATION
Member #_______________
The Retired Association for the Uniformed Services, Inc.
504 Autumn Springs Court, Suite 8, Franklin, TN 37067-8278
Certificate #_____________
800-321-RAUS Fax 615-790-2210
Member Name:
___________________________________________________________________/____/________
Last Name
First Name
Initial
Social Security #
Date of Birth
Spouse Name:
___________________________________________________________________/____/________
Last Name
First Name
Initial
Social Security #
Date of Birth
Address:
________________________________________________________________________________
Street
City
State
ZIP
Military Data:
_______|_____|____________ ____/____/____ ____/____/____ ________________________
Branch
Rank
Service #
Military Entry Date
Discharge Date
Email Address
Check One:
____/____/____
[ ]
[ ]
[ ]
[ ]
Retired
Widow(er)
TRR
Active Duty
Military Retirement Date:
DUES RATES
Amount
I hereby request membership in RAUS to take advantage of the member-
only association benefits. I have included the initial membership dues and
[ ] 1 year membership
$15.00
understand that, except for Life Membership, continued membership and
[ ] 3 year membership
$37.00
benefit enjoyment requires renewal of my membership upon expiration of
[ ] 5 year membership
$60.00
the initial period.
[ ] Life memberships are based on age. (See below)
Date_________________
Phone: ________________ Signed: ______________________________________
Life Membership
AGE RANGE
40 or less 41 to 45 46 to 50 51 to 55 56 to 60 61 to 65 66 to 70 70 and up
LIFE DUES
$325
$300
$275
$250
$225
$200
$175
$100
THE RAUS ASSOCIATION
RAUS is a non-political military association organized in 1970 to secure quality benefits for its members at
rates only available to groups. Qualified retired and active members of the United States armed forces and
related departments may join RAUS by making application and paying the membership dues. Association
benefits are available to all members, their spouses and eligible dependents. The various association benefits
are designed for the needs of the general membership and therefore will change from time to time. The asso-
ciation objective is to always provide membership benefits as follows: newsletter; insurance products; dis-
count buying and travel services; credit cards; other products and services as deemed feasible.
WHO MAY JOIN THE ASSOCIATION?
Both Retired and Active duty military personnel may join the Association. All military branches and military
ranks are eligible. Membership and benefits are available to:
1. military members
4. widows
2. military spouse
5. widowers
3. members dependents
6. former spouse
AIR FORCE
COAST GUARD
CIVIL AIR PATROL
ARMY
COSTAL & GEODETIC SURVEY
NOAA
MARINES
PUBLIC HEALTH SERVICE
ACTIVE & RETIRED
NAVY
NATIONAL GUARD
OFFICER & ENLISTED
Write two checks--one check for your premium payable to SelmanCo, and one for your dues payable to
RAUS. Mail membership application and enrollment forms with your checks for dues and premium to:
RAUS
504 Autumn Springs Court, Suite 8
Franklin, TN 37067-8278
1-800-321-RAUS (7287)
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