International Police Association Region 56 Wisconsin
INTERNATIONAL POLICE ASSOCIATION
UNITED STATES SECTION
Membership Application
Please print or type all answers
Name in Full ______________________________________________________________ Home
Phone (____)______________________
Address: City, State,
Zip________________________________________________________________
___________________________
____________________________________________________________________________
County, ____________________________
Birthdate __________________ ___Male or ___Female
Agency__________________________________________________________________________________________
Date Joined Law Enforcement Agency_______________________________________
Business Phone (_____)______________________
Position________________________ Retirement Date(if app.)____________
Have you previously been an I.P.A. member? ___Yes ____No Previous IPA Number (if
app) ______________________________
E-mail address _____________________________________ Web Page (Dept. or
personal) _____________________________________
MEMBERSHIP STATEMENT
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:_____________________
PAYMENT
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). 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.
Payments may be deductible as miscellaneous itemized deductions for Federal Tax
purposes.
You may use MC/Visa/AX Credit Card
#_______________________________________________ Ex________
VERIFICATION
Send a copy of both sides of your law enforcement I.D. OR have the application
certified by a member (see below)
This area for member recommending new applicant:
I do hereby certify that the above applicant meets all requirements for
membership in the International Police Association.
Recommended by: Signature __________________________________IPA #
_____________Region #________
Action taken or remarks:
------------------------------------------------------------------------------------------------------------
Mail Completed Application to:
IPA Region 56 -Wisconsin
1269 Reed Street
Green Bay, WI 54303
FORM IPA-05
05/05
For office use only
Date of enrollment____________
Date of reinstatement__________
IPA/USA #__________________
Action taken or remarks:
www.ipa-usa.org info@ipa-usa.org