Region *Membership Application for year 20 Renewal New Associate Special Dual Life *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? Yes No If Yes, What Type? (PD 1, PD 2 Detector) USPCA Certified National Judge? Yes No If Yes, What Type and national number?(PD1 Detector) USPCA Certified Trainer? Yes No 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