MEMBERSHIP APPLICATION FORM

INTERNATIONAL POLICE ASSOCIATION - UNITED STATES SECTION – Region 62

Print this application and mail it to:

Diane MacGregor Region 62 Application

IPA National Membership Secretary For office use only Date received __________

511 N. Reese Street Date Enrolled _________ Date Reinstated _________

South Lyon, MI 48178-1267 IPA/USA No. _________ Action taken / remarks___________

Please Print or Type all Answers to Questions.

Name (Full) __________________________ _________________________ ____________ ___________

Last First Middle (or Initial) Suffix Jr/Sr/etc.

Address: ________________________________________ __________________________ _______ _______-____

Number Street City State Zip

(___)_____________________ ___________________________ (____)_________________ (____)________________

Home Phone e-mail address Work Phone Fax or cell phone number if applicable

Birthdate ______________(Male) _____ (Female) _____ Spouse's Name (if applicable)___________________________________

mo/day/year

Membership is open to all active serving or retired sworn members of a duly organized local, city, state, or federal law enforcement agency or department, who are or were employed full time in the enforcement of the general criminal laws of their state or of the federal government. If retired, retirement must be based upon 20 years or more of service, or be of a disability nature. Members of the Military Police are not qualified for membership. Status will be verified.

Law Enforcement Agency Name: ______________________________________________________________________

Agency address: ________________________________________ __________________________ _______ _______-____

Number Street City State Zip

Agency Phone Number (____)__________________. Your office work number (_____)____________________

Date joined law enforcement agency______________________ Present position/rank/duty _________________________

Badge, shield, or ID number:__________. If retired, date of retirement ______________ .Reason (if less than 20 yrs) _______________

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 I shall conform to the Rules of the United States Section of the International Police Association. If accepted as a member, I will endeavor to further the work of the Association by fulfilling the obligations of membership. I hereby submit my membership fee and pledge to regularly subscribe my renewal fee at the prescribed time 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 Law Enforcement Officer for the Agency or Department listed above. I hereby release any individual, organization, or agency from any and all liability incurred as a result of providing such information.

Signed: _________________________________________________ Date:_______________________

Please include a copy of both sides of your law enforcement I.D. As an alternative, you may have the application certified by a current member of the IPA region. (You can even do both and see how fast we can work to get it confirmed, verified, approved, and your membership items back to you.)

Include your check for the membership fee in the amount of $25, payable to the International Police Association. (Renewal dues are also $25. per year.) Payments may be deductible as miscellaneous itemized deductions (professional association dues) for income tax purposes.

The official enrollment date will be the date that the member is enrolled. A membership number is issued by the National Secretary General, U.S. Section. After the application is [rocessed the member shall receive a current IPA membership ID card and lapel pin, and will be subscribed to receive the National Newsletter, Regional Newsletters, and RemNet [regional e-mail network] bulletins.

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

Your SSN social security # (optional) _________________ Languages Spoken:____________________________________________

Are you able to accommodate members of the I.P.A. from other countries, or other parts of the U.S.? Yes ____No____. If yes, please state which services you could provide: (room, meals, use of car, etc.) __________________________________________________

Are you willing to show visitors various points of interest in your area? Yes _____No_____. Do you have access to any special areas of interest to our member visitors? If so, please list:_________________________________________________________________

I do hereby certify that the above applicant meets all requirements for membership in the International Police Association and heartily recommend the applicant for membership.

IPA member recommending new applicant - please print name: ________________________________________________

Signature ________________________________________ IPA # ______________ Region #________

Region 62 membership application form rev 2/26/2010