Chester County
           Police Chiefs Association

        Membership Application

Please print application, complete and send with check for $75.00 Membership Fee to:

Chester County Police Chiefs Association
P.O. Box 278
West Chester, PA  19380

 

ACTIVE MEMBER □                  ASSOCIATE MEMBER □
DATE OF APPLICATION: _______________                    DATE OF BIRTH: _________________
NAME: _________________________________________________________________________
STREET ADDRESS:______________________________________________________________
CITY: ________________________________        STATE: ________      ZIP CODE: __________
RES. TELEPHONE: ____________________        BUS. TELEPHONE: _____________________
TITLE/POSITION: ________________________________________________________________
DEPARTMENT or EMPLOYER: ____________________________________________________
STREET ADDRESS:_______________________________________________________________
CITY: ________________________________        STATE: ________      ZIP CODE: __________
BUSINESS FAX: _______________________       E-MAIL: _______________________________


INFORMATION MAY BE PUBLISHED AS FOLLOWS:

ADDRESS FOR MAILING PURPOSES:            HOME □                           BUSINESS □
ALL ABOVE  □              HOME ONLY  □        BUSINESS ONLY  □           ALL BUT HOME PHONE  □
RECOMMENDED FOR MEMBERSHIP BY: _________________________________________
TITLE: _______________          DEPARTMENT/EMPLOYER: ___________________________

TO BE COMPLETED BY
MEMBERSHIP COMMITTEE

APPROVED  □   REJECTED  □   CHAIRMAN SIGNATURE: _________________________________
DATE APPROVED:  __________________              SEC. COPY  □        FINANCIAL SECRETARY COPY  □

            CCPCA  3/12/04                 Home