Membership App

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