Application For Membership - Virginia State Police Alumni
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1Virginia State Police Alumni
APPLICATION
2484 Riverville Road
FOR
Gladstone, VA 24553
MEMBERSHIP
GOAL OF
:
THE VIRGINIA STATE POLICE ALUMNI
T o for m a b od y o f perso ns for mer ly members or employe es o f th e Virg in ia Sta te Po lic e , to un ite
i t s me mb ers in th e c l oses t bon d o f goo d fe llow s hi p , and to pro mote a closer b usiness an d soc ia l
u ni on a mon g the m . It s h al l r ema in a fra t ern al org an iz a t io n w i t hou t po li t ic a l as pi r a t ions.
L A S T N A M E
F I R S T N A M E
M I D D L E N A M E
N I C K N A M E
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A D D R E S S
S T R E E T O R P
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B O X
C I T Y O R T O W N
S T A T E
Z I P
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D A T E O F B I R T H
S P O U S E N A M E
R E S I D E N C E P H O N E
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M A I L A D D R E S S
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D
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E R V E D A S A
M E M B E R
O R
E M P L O Y E E O F T H E
E P A R T M E N T O F
T A T E
O L I C E
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C H E C K A P P R O P R I A T E B O X
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T
R O M
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M O N T H
Y E A R
M O N T H
Y E A R
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T A T I O N
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P R E S E N T E M P L O Y E R
P O S I T I O N
B U S I N E S S P H O N E
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B U S I N E S S A D D R E S S
S T R E E T O R P
O
B O X
C I T Y O R T O W N
S T A T E
Z I P
I c er t i f y tha t I di d no t r e t ir e , r es ig n or le a ve t h e D ep ar tm en t o f S ta t e P o lic e u nde r c ir c um s tanc es ,
w h ich are c o n tr ar y t o t h e bes t int er es ts o f th e Vir gi ni a S t a te P ol ic e A lu mn i , I nc .
D
S
A T E
I G N A T U R E
A n nua l D ues – $2 5 .00
I n i t ia t ion Fe e – $ 10 .00
An nua l d ues ar e p a yab le on o r be fore J anua r y 1 , eac h ye ar .
If a pp lic an t is no t acce p tab le for members hip , a ll pa ymen ts w i ll b e re fund ed .
No te : Dues a nd In itiation Fe e mus t accompa n y th is app lica tion .
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