Page 15 - TPA Journal Sept Oct 2021
P. 15
Registration Fee: $845.00- TPA Member
$895.00- Non-member
Or
Click Here to Register On-Line: Register Here (Credit Card Fees Apply)
Complete the form below and return it with payment
Texas Police Association Return This Form To: Texas Police Association
Registration Form P. O. Box 4247, Austin, TX 78765
Law Enforcement Leadership Conference Phone (512) 458-3140
mona@texaspoliceassociation.com
TCOLE ID# Last Name (Include Sr., Jr., Etc.) First Name Middle Initial
Date of Birth (mo-day-yr) Registrant’s Rank or Title Classification: [ ] Peace Officer [ ] Corrections
[ ] Reserve Officer [ ] Elected Official
[ ] Other
Name of Law Enforcement Agency Address City Zip
Agency Telephone Number E-mail address
Return Confirmation & Receipt to:
TPA Use Only:
Date Confirmation Mailed/Faxed/E-Mailed:
Paid: $ [ ] City/County/State Check [ ] Personal Check #
Am Express Discover MasterCard ___ Visa
Name
Card Number Expiration Date
Security Code Signature
Credit Card fees will be passed along to the Registrant.
Feel free to duplicate this form as may be needed.
