Page 10 - TPA Journal November-December 2018
P. 10
GIFT Application for Membership
Texas Police Association
Active (Law Enforcement) - $30.00 Agency Affiliate - $25.00 Per Officer
Name Date of Birth
Agency/Company Title
Mailing Address
City State Zip
Contact Phone Number
E-mail Address
Name of Beneficiary
(Active Membership Includes $7,500.00 IN THE LINE OF DUTY & Accidental Death Benefit)
I certify that the beneficiary named above is correct according to my wishes.
Signature Date
Mail Application and Dues to: Texas Police Association, P. O. Box 4247, Austin, Texas 78765-4247
Special Gift from:
Name Email Address
GIFT Application for Membership
Texas Police Association
Student - $10.00 Citizen - $150.00 Business - $500.00 Donation - $
Name
Agency/Company Title
Mailing Address
City State Zip
E-mail Address
Contact Phone Number
Signature Date
Mail Application and Dues to: Texas Police Association, P. O. Box 4247, Austin, Texas 78765-4247
Special Gift from:
Name Email Address
Nov./Dec. 2018 www.texaspoliceassociation.com • 866-997-8282 5
