top of page
MEMBERSHIP APPLICATION
Dues for 2023 are Due, dues are $30.00 per year
and
"Life TIME" Members PAY $10.00 Assessment
Right Click The Docx Below To Download The Application
Type Info Into the Application Docx Below
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’S FUND _____________________________
BIRTH DATE ____/____/______ ANNUAL DUES ARE $30.00 CHECK #_____________
APPOINTMENT DATE____/____/_______ RETIREMENT DATE ___/___/______
ATTACH Photo Copy
of DEPT ID
PENSION #(REQ'D)__________________ LAST COMMAND_____________ LAST RANK________
LIST ALL PREVIOUS COMMANDS ___________________________________________________
ASSOCIATE MEMBERS
LAW ENFORCEMENT AGENCY________________________TELEPHONE ( ) ________________
RANK_______ RETIRED ( ) ACTIVE ( ) MILITARY ACTIVE ( ) RETIRED ( )
Signature______________________ Date ____ /_____ /_______
MAKE CHECK PAYABLE TO: NE, FL 10-13 SEND to PO Box 291862, Port Orange FL 32129
ALONG WITH THIS APPLICATION, & PHOTO COPY DEPT ID

bottom of page