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International Police Association

United States Region 43 Application Form

 

Please supply us with the following information:


Section I


Gender Mr.Ms.
Name: 
Address: 
City: 
County: (not Country) 
State: 
Zip Code: 
Fax Number: including area code
E-Mail:


Section II


Law Enforcement Agency:(documentation must follow if requested)
Date Joined: 
Position/Duty: 
Business Phone:
If Retired, Date Of Retirement:If less than 20 years documentation must follow
if requested. (example, 11-7-98, disability)
Social Security Number: (Optional)


Section III


 
Previous I.P.A. member  YesNo
If you where a previous member, what was your membership number?
Lanquages spoken:
Can you accommodate IPA members from other countries or
the US?		 YesNo

If "Yes" What Below Services Could you Provide:


Use of Car: please check 
Room: please check 
Meals: please check 
Other: please explain:
Are you willing to show visitors points of
interest? 		 YesNo
Referred by member, please state his/her name
Referring members membership number:
Referring members e-mail address
Referring members IPA Region number 


Upon Receipt of your online application a formal application will be mailed
to you, please fill out the foral application and mail it in with
your check in the amount of  $25.00.


 
 

Copyright (c) 1999 International Police Association Region 43

Updated  March 1, 2000

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