MEMBERSHIP APPLICATION

(Please Print Out and Mail back to the address below.) (Click here to return to the Opening Page.)

Type of Membership:                                               Date:   __________________

 ____  Regular (Sworn, Active, Retired, or Former Full-time Law Enforcement Officer of Irish Heritage.)

 ____ Associate (Non-voting). * Society member sponsoring new Associate:___________________.

                   _____  Renewal of Membership                     _____   New Membership

Personal Information:

Last Name, First Name, MI (Please Print) 
 

_______________________________________________________________________________

Home Telephone Number/E-Mail Address

_______________________________________________________________________________

Home Address                                                  City, State, Zip Code

________________________________________________________________________________

Work Information:  
Agency/Division (Current or Retired From)        Assignment (or Retired)

__________________________________________________________________________________________

Serial Number                   Work Telephone Number/E-mail Address at Work if different from above.

_________________________________________________________________________________

Emergency Contact Information:

Emergency Contact Name/Relationship    

_____________________________________________________________________________________
Day Telephone Number                                       Evening Telephone Number
_________________________________________________________________________________

Annual dues are $25.00.  Please include a check in that amount with this completed application and mail to:

Los Angeles Police Emerald Society

714 West Olympic Boulevard, Suite 630

Los Angeles, CA 90015

Telephone Number: (213) 7IRISH3 (213) 747-4743

Web Site Address:  www.emeraldsociety.net  Or to return to the Home Page or Opening Page click on either one.)