Active Membership Application

Annual dues: $50. For active or retired law enforcement.

Your Information

Last Name *

First Name *

M.I.

Address

City

State

ZIP

Home Phone

Email *

Date of Birth

Law Enforcement Service

Rank

Agency

Command

Status

Department ID Copy *

PDF, JPG, or PNG. Maximum 5 MB.

Beneficiary

Relationship

Certification

I certify that the information provided is true and complete.

Signature (type your full name)

Date