ILPWDA MEMBERSHIP APPLICATION

MEMBERSHIP APPLICATION

Annual Dues: Regular and Association Members - $30.00 Per Year

Today's Date: _______/_______/_______

Last Name: _____________________________ First: _________________________ MI: ______

Home Address: ___________________________________________________________________

City: _______________________________ State: ___________________ Zip: ________________

Home Phone Number: (area code) _____________ - _____________ - ____________

Pager and/or Cell Phone: ___________________________________________________________

Home E-Mail Address: ____________________________________________________________

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Regular Member

Are you an active Law Enforcement Officer? Yes _____ No_____

Does your Law Enforcement Employer use you and the K9? Yes_____ No _____

Are you a retired law enforcement officer? Yes _____ No _____

Police Department - Agency Employed by: ___________________________________________

Work Address: __________________________________________________________________

City: ________________________________ State: __________________ Zip: ______________

Work Phone Number: (area code) __________ - __________ - __________

Work E-Mail Address: ____________________________________________________________

Position - (Circle One) Handler Retired Handler Trainer Other (describe):

Associate Member

Last Name: ___________________________ First: ___________________________ MI: _______

Home Address: ___________________________________________________________________

City: ________________________________ State: ____________________ Zip: ______________

Home Phone Number: (area code) ____________ - ____________ - ____________

Regular ILPWDA Member Sponsoring You - Signed: __________________________________

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K-9

K-9's Name: _____________________________ Age: __________ Sex: M F

Breed: _____________________________________ Color: _____________________________

Dual Purpose: __________ Narcotic Only: __________ Explosive Detection: __________

Accelerant: __________ S & R: __________ Other:____________________________

Please print this page, fill it out, and mail with fees payable to ILPWDA to:

(815) 955-1791

Annual Dues: Regular and Association Members - $30.00 Per Year

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