MEMBERSHIP APPLICATION
PLEASE PRINT ALL REQUESTED INFORMATION
LAST NAME_________________________ FIRST____________________ MI____
ADDRESS________________________ CITY__________________ STATE_____
ZIP CODE________ HOME PHONE (___)__________ CELL (__)_______________
SPOUSE'S NAME___________________ EMAIL ADDRESS___________________
BENEFICIARY'S NAME FOR SURVIVOR FUND_____________________________
BIRTH DATE_____/____/____     ANNUAL DUES ARE $30.00     CHECK #_______
APPOINTMENT DATE _____/_____/_____ RETIREMENT DATE _____/_____/____
PENSION #(REQ'D) _________ LAST COMMAND________ LAST RANK________
LIST ALL PREVIOUS COMMANDS_______________________________________
__________________________________________________________________
ASSOCIATE MEMBERS
LAW ENFORCEMENT AGENCY_____________________ RANK_______________
LAW ENFORCEMENT TELEPHONE (____)_________________________________
RETIRED (__) ACTIVE (__)         MILITARY (___) ACTIVE   (___) RETIRED
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 _____/_____/_____
LIFETIME MEMBERS PAY $10.00 YEARLY Assessment
MAKE CHECKS PAYABLE TO:
NE FL 10-13
P.O. BOX 4025
Enterprise, FL 32725

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