Page 10 - Texas Police Journal November- December 2013
P. 10
Texas Police Association Return This Form To: Texas Police Association
Registration Form P. O. Box 4247, Austin, TX 78765
Law Enforcement Administrators Conference Fax (512) 458-1799: (512) 458-3140
TCLEOSE ID# Last Name (Include Sr., Jr., Etc.) First Name Middle Initial
Date of Birth (mo-day-yr) Registrants 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 Exp Discover MasterCard ___ Visa
Name
Card Number Expiration Date
Security Code Signature
Feel free to duplicate this form as may be needed.
8 www.texaspoliceassociation.com • 866-997-8282 Texas Police Journal
