MEMBERSHIP APPLICATION FORM Please Print or Type All Answers To Questions *For office use only*Date of Enrollment _________*Date of Reinstatement ____________*IPA/U.S.A. Number ________*Action taken or remarks_____________RETURN TO: Region 44 IPA, 3746 Hemlock Dr. San Bernardino, Ca. 92404 email <ipabob@earthlink.net> (Begin Below)

Name in Full __________________________________________Home Phone +AC(____________)

Address: City, State, County, Zip ____________________________________________________________

Birthdate ______________(M) _____ (F) _____ Spouse's Name (if any) _____________________________

LawEnforcementAgency_________________________________________________________________________

Date Join Law Enforcement Agency________________ Business Phone +AC(_____________) Position/Duty____________________________Date of Retirement____________Reason_______________ Have you previously been an I.P.A. member? Yes____No____Previous IPA Number ____________

I declare my desire for Membership in the U.S. Section of the International Police Association. I agree with the aims and objectives of the Association as outlined in the Statutes and Standing Orders, and that I shall conform to the Rules of the United States Section of the International Police Association. If accepted, I will endeavor to further the work of the Association by fulfilling the obligations of membership, and will submit my membership fee and regularly subscribe my renewal fee by the 1st of January each year to remain a member in good standing. I hereby authorize the Secretary General of the United States Section of the IPA to confirm and verify my status as a bonafide Police Agent or Officer for the Agency listed above. I release any individual, organization or agency from any and all liability incurred as a result of providing such information.

Signed: _________________________________________ Date:_______________________

Make all checks payable to INTERNATIONAL POLICE ASSOCIATION. Membership shall be open to all serving and/or retired members of a duly organized Police Force, Department, or Agency, who are or were employed full time in the enforcement of the general criminal laws of their State or the United States Government (except members of the Military Police).

Send a copy of both sides of your law enforcement I.D. or have the application certified by a member (see below) Membership fee, upon application, is $25.00. Renewal dues shall be $20.00 per year. The enrollment date is the date the member is enrolled, and a number is issued, by the National Secretary General, U.S. Section. When the number is obtained by the Region, the member shall receive an International Membership Passport, Lapel Pin and National Newsletter.

Answers to the following optional questions are not a prerequisite for gaining membership in the I.P.A.

Social Security # (optional) ________________E-mail address ____________________________

Languages Spoken:______________________________________________________________

Can you accommodate members of the I.P.A. from other countries or other parts of the U.S.? Yes____No____

If "yes," please state what services you could provide (use of car, room, meals, etc.) ____________________

Are you willing to show visitors points of interest? Yes_____No_____

This area for member recommending new applicant: (or attach a copy of both sides of your law enforcement agency I.D.) I do hereby certify that the above applicant meets all requirements for membership in the International Police Association.

Recommended by: Signature ________________________________IPA # __________Region #_________