POLICE ASSOCIATION FOR COLLEGE EDUCATION

Louis A. Mayo, Ph.D., Executive Director

APPLICATION FOR MEMBERSHIP

 NAME                                                                                             ___          DATE                              

RESIDENCE ADDRESS                                                                                                                         

CITY                                                      STATE                    ZIP                TEL.                                  

LAW ENFORCEMENT AGENCY                                                                                                               

ADDRESS                                           CITY                                                                                    

STATE            ZIP CODE                         TEL.                                   FAX                                            

E-MAIL                                                    MAIL TO:                       RESIDENCE                        AGENCY            

APPOINTMENT DATE AS AN OFFICER                         CURRENT POSITION                                            

PRIOR POLICE SERVICE                                                                                                                    

                                                                                                                                       

COLLEGE or UNIVERSITY             DEGREE                     YEAR          MAJOR            

                                                                                                                                                                                                                                                          

ARE YOU CURRENTLY ENROLLED IN COLLEGE                     YES           NO    

IF YES, COLLEGE                                           MAJOR                        ____________________________

CREDITS COMPLETED                            DEGREE ANTICIPATED                               DATE  __________

DOES YOUR DEPARTMENT HAVE A COLLEGE REQUIREMENT FOR:

ENTRANCE                                                                   DEGREE OR NUMBER OF CREDITS                              

PROMOTION                                                                 DEGREE OR NUMBER OF CREDITS                             

DOES YOUR DEPARTMENT HAVE:

TUITION REIMBURSEMENT?                                                        DESCRIBE_________________________

 EDUCATIONAL INCENTIVE PAY?                                                DESCRIBE                                               

Please fill out and mail  this form with your check (if any) to the above address .

DONATION ENCLOSED:

$5___ $10___ $15.00___ $25___ $35___ $50___ $75___ $100.00