MEMBERSHIP APPLICATION
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PLEASE PRINT ALL REQUESTED INFORMATION
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LAST NAME_________________________ FIRST____________________ MI____
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ADDRESS________________________ CITY__________________ STATE_____
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ZIP CODE________ HOME PHONE (___)__________ CELL (__)_______________
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SPOUSE'S NAME___________________ EMAIL ADDRESS___________________
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BENEFICIARY'S NAME FOR SURVIVOR FUND_____________________________
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BIRTH DATE_____/____/____ ANNUAL DUES ARE $30.00 CHECK #_______
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APPOINTMENT DATE _____/_____/_____ RETIREMENT DATE _____/_____/____
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PENSION #(REQ'D) _________ LAST COMMAND________ LAST RANK________
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LIST ALL PREVIOUS COMMANDS_______________________________________
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__________________________________________________________________
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ASSOCIATE MEMBERS
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LAW ENFORCEMENT AGENCY_____________________ RANK_______________
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LAW ENFORCEMENT TELEPHONE (____)_________________________________
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RETIRED (__) ACTIVE (__) MILITARY (___) ACTIVE (___) RETIRED
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I declare my desire for membership in the Northeast Florida 10-13 club
and to abide by the rules and constitution of the club. Furthermore, I promise to remain a member in good standing and to submit my yearly dues on or about the 1st of January. By affixing my signature below, I attest to the above as being true and to the best of my knowledge. |
Signature_____________________________________ Date _____/_____/_____
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LIFETIME MEMBERS PAY $10.00 YEARLY Assessment
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MAKE CHECKS PAYABLE TO:
NE FL 10-13 P.O. BOX 4025 Enterprise, FL 32725 |