VIRGINIA POLICE WORK DOG ASSOCIATION

MEMBERSHIP APPLICATION

ANNUAL DUES: REGULAR MEMBER - $20.00 PER YEAR

ASSOCIATE MEMBER - $25.00 PER YEAR

Today’s Date / / / Check If New Member: Yes _____ No _______

Social Security Number: / / / Date of Birth: / / /

Last Name: ___________________________ First Name: ___________________ MI:_______

Home Address: _______________________________________________________________________

City:______________________________________ State:______________________ Zip: _________

Home Phone Number (Area code) ( ) ___________ - ___________

E-MAIL ADDRESS: ___________________________________________________________________

Regular Member

What position do you hold with your Department? _________________________________________

1. (a) Are you a Law Enforcement Officer? __Yes __no (b) Do you have arrest powers? __yes __no

(c) Are you a Retired Law Enforcement Officer who had the power of arrest before you retired __yes ___no

( IF THE ANSWER TO QUESTION 1, PART (A) OR (B) IS NO, UNLESS THE ANSWER TO

QUESTION 1, PART C IS YES, YOU CANNOT JOIN AS A REGULAR MEMBER

Law Enforcement Department Employer Name: ____________________________________________

Work Address: ________________________________________________________________________

City: ____________________________________ State: ______________________ Zip: __________

Department Phone Number: (Area Code) ( ) _______ - ____________________

Position Held in K-9 Unit: Handler, Trainer, Other – describe:_____________________________

*I Hereby Acknowledge That The Above Statements Are True:_______________________________

(Applicant must sign the above statement) (Signature)

*************************************************************************************Associate Member

(Associate Member – must be sponsored by a Regular Member and re-sponsored each year)

Last Name: _________________________ First: ____________________ MI: _____________

Home Address: ______________________________________________________________________

City: _______________________________________ State: ____________________ Zip: _________

Home Phone Number (Area Code) ( ) ________- ______________

Occupation:_________________________________________________________________________

Regular member’s Signature that is Sponsoring You: _______________________________________

Sponsor – print your name here: _________________________________________________________

Print your phone number here: (The Vpwda will confirm your sponsorship) _____________________

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SEND MEMBERSHIP FORM ALONG WITH FEES TO:

V.P.W.D.A. Membership Chairman

PO Box 71925, Richmond, Virginia 23255

MAKE CHECKS PAYABLE TO: V.P.W.D.A.

DUES: REGULAR MEMBERS - $20.00

DUES: ASSOCIATE MEMBERS - $25.00

DUES: LATE RENEWAL OF MEMBER SHIP – ADD AN EXTRA $5.00