INTERNATIONALPOLICE ASSOCIATION UNITED STATES SECTION

MEMBERSHIP APPLICATION FORM Please Print or Type All AnswersTo Questions *For office use only*Date of Enrollment_________*Date of Reinstatement ____________*IPA/U.S.A. Number_________________*Action taken or remarks______________RETURN TO: IPA Region 33: 95-1036 Kamalino St. Mililani, HI  96789-4975  email <r33ipahi@lava.net>(Begin Below)

Name in Full __________________________________________HomePhone +AC(____________)

Full Address City State Zip ________________________________________________________________

Birthdate ______________(M) _____ (F) _____ Spouse's Name(if any) _____________________________

LawEnforcementAgency_________________________________________________________________________

Date Join Law Enforcement Agency________________ BusinessPhone +AC(_____________) Position/Duty____________________________Dateof Retirement____________Reason_______________ Have you previously beenan I.P.A. member? Yes____No____Previous IPA Number ____________

I declare my desire for Membership in the U.S. Sectionof the International Police Association. I agree with the aims and objectivesof the Association as outlined in the Statutes and Standing Orders, andthat I shall conform to the Rules of the United States Section of the InternationalPolice Association. If accepted, I will endeavor to further the work ofthe Association by fulfilling the obligations of membership, and will submitmy membership fee and regularly subscribe my renewal fee by the 1st ofJanuary each year to remain a member in good standing. I hereby authorizethe Secretary General of the United States Section of the IPA to confirmand verify my status as a bonafide Police Agent or Officer for the Agencylisted above. I release any individual, organization or agency from anyand all liability incurred as a result of providing such information.

Signed: _________________________________________ Date:_______________________

Make all checks payable to INTERNATIONAL POLICE ASSOCIATION.Membership shall be open to all serving and/or retiredmembers of a duly organized Police Force, Department, or Agency, who areor were employed full time in the enforcement of the general criminal lawsof their State or the United States Government (except members of the MilitaryPolice).

Send a copy of both sides of your law enforcement I.D. or have theapplication certified by a member (see below) Membershipfee, upon application, is $25.00. Renewal dues shall be $20.00 per year.The enrollment date is the date the member is enrolled, and a number isissued, by the National Secretary General, U.S. Section. When the numberis obtained by the Region, the member shall receive an International MembershipPassport, Lapel Pin and National Newsletter.

Answers to the following optional questions are not aprerequisite for gaining membership in the I.P.A.

Social Security # (optional) ________________E-mail address____________________________

Languages Spoken:______________________________________________________________

Can you accommodate members of the I.P.A. from other countriesor other parts of the U.S.? Yes____No____

If "yes," please state what services you couldprovide (use of car, room, meals, etc.) ____________________

Are you willing to show visitors points of interest? Yes_____No_____

This area for member recommending new applicant: (or attacha copy of both sides of your law enforcement agency I.D.) I do hereby certifythat the above applicant meets all requirements for membership in the InternationalPolice Association.

Recommended by: Signature ________________________________IPA# __________Region #_________