N/NJPSC INC. MEMBERSHIP APPLICATION

APPLICATION FOR MEMBERSHIP



Name: _____________________________ Date:___________

Address:_______________________________________

City, State, Zip: ________________________________________

Dept./Organization: _____________________________________

Dept./Org. Address: _____________________________________

Rank/Title: ____________________________________________

Years of Service: ________________________________________

Dept./Org. Phone: (____) _________Best Contact # (_____)______

Cell# (____) _____________ E-Mail (optional) _______________

Marital Status: ___________________________________________
Married, Single, Divorced, Cohabitants, Other

Sex:_______(M/F) Age:________ Dob: ________________

Status: Active _____ Retired ______Suspended ______ Terminated _____


Member # __________ (Check one if applicable )
(Official Use Only)

Membership Fee: $25.00
Please make checks payable to:
(Tax –Deductible) New Jersey Police Solidarity Coalition Inc.
P.O. Box #72
South Orange, N.J. 07079-9998
Form#M-1 www.npscinc.blogger.com