About the USPCA Regional Information Events  
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United States Police Canine Association Region 3
A Professional Law Enforecement Canine Training and Certifying Association

The United States Police Canine Association, Inc– Region Three

Membership Application

*** ALL APPLICABLE FIELDS ARE REQUIRED***

You must pay your dues when you submit an application to join or renew

Region
Membership Application for year
20
Name
Home Telephone
Address
Cell Number
C/S/Z
Date Of Birth
Email Address
Agency
Work Telephone
Address
C/S/Z
Number of Years Employed
 
Rank
Assignment (Handler/Trainer/ Administrator/Retired)
K9 Name
Breed
Age
K9 Name
Breed
Age
Patrol Trained
Narcotic Trained
Explosive Trained
Other
List Appropriate Dates & Agency Where Basic or Advanced Training Was Completed
USPCA Certified Region Judge?
If Yes, What Type? (PD 1, PD 2 Detector)
USPCA Certified National Judge?
Yes
If Yes, What Type and national number?(PD1 Detector)
USPCA Certified Trainer? Yes
If Yes, What Level?
 
Death Beneficiary Information (Line of Duty Death Only) :
Name
Telephone
Address
C/S/Z
Relationship
Typing in your name serves as your signature
Form Completion Date
 
   

 

 

 

     
 

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2002-2007 United States Police Canine Association, Inc. Region Three
633 Pennsylvania Ave SE #243 Washington, DC 20003
Fax: (888) 528-6610
Questions or Comments Please e-mail us: ceo@kubitt.com

 
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