MEMBERSHIP APPLICATION

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:  ____________________________

Continue on back if necessary

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.