APPLICATION FOR MEMBERSHIP

I hereby make application for membership in the FLORIDA PEACE OFFICERS’ ASSOCIATION, INC., subject to the Articles and Bylaws of said Association. 

[All applications must be accompanied with dues for one year, which will be refunded if application is rejected.  Make checks payable to Florida Peace Officers’ Association, Inc.]

NEW MEMBER
RE-INSTATEMENT
RENEWAL
Current Card # (If Re-Instating or Renewing)
Are You A Shooter?

Name: 
Street Address: 
City: 
County: 
State: 
Zip: 
Cell Phone#: 
Home Phone#: 
Date of Birth: 
Email Address: 
Agency Employed By: 
Job Title: 
Office Location: 
Work Phone #: 
 

*REQUIRED FOR NEW MEMBER APPLICANTS ONLY   *If not a regularly employed, full time Law Enforcement Officer, specify the qualifications under which you request membership, such as Special Police; Special Deputy; Auxiliary Police, etc.

I certify that the above statements are true:    

Check here if change of beneficiary only, and enter beneficiary name and address.
*RECOMMENDED BY F.P.O.A. MEMBER
*CARD NO.: 
*BENEFICIARY 
[Free $3,500 A D & D]  
*ADDRESS: 
CITY: 
STATE: 
ZIP: 
Active life $375
Associate $30 Associate Life $450
Senior Active $12.50 Ladies Auxillary $15
Youth $20 Ladies Auxiliary Life $225

Payment Method:
Master Card        Visa        Discover
Card Number:
Expiration Date: