DATE: _____________________
NAME: _________________________ HOME PHONE __________________________
ADDRESS: _____________________________________________________________________
DOB: ______________________ SSN ___________________________
EMPLOYED BY: _______________________________________________________________
ADDRESS:______________________________________________________________________
RANK _______________ OFFICE PHONE ___________________ FAX ________________
POSITION: ____________________________ OTHER: ____________________________
Handler, Trainer, Administrator, Etc Specify
K-9 NAME: _______________________ BREED: ____________________________
TYPE OF TRAINING: ____________________________________________________________
______ I AM A NEW MEMBER _____ Please renew my membership
Please submit your application and $25.00 membership fee to:
WVPCA
DOUG ADAMS
PO BOX 292
LESAGE, WV 25537
PLEASE MAKE CHECK PAYABLE TO: WVPCA
______ I AM A NEW MEMBER _____ Please renew my membership
NOTE: Regular Members include Police Officers and Administrators.
Associate Members are members that are not affiliated with a Police Department.
Associate Members have to be sponsored by a regular member.
Place the sponsors name in the section above marked EMPLOYED BY.