Membership App.

SOUTH CAROLINA POLICE k-9 ASSOCIATION

SOUTH CAROLINA POLICE K-9 ASSOCIATION

Membership Application

Active Membership ($50.00)

Associate Membership ($25.00)

Advisor

Date:

Last Name: First MI:

Address: City

State: Zip: E-Mail:

Phone #: (H) (C) (P)

Date of Birth: SSN:

Law Enforcement Years: Years Working K9:

Years Instructing K-9: E-Mail:

Certifications with K-9

Agency: Address:

City: State: Zip:

K-9 Name: Breed: Age: Sex:

Function: (circle which applies) Patrol – Narcotics – Explosive – Tracking – Other

K-9 Name: Breed: Age: Sex:

Function: (circle which applies) Patrol – Narcotics – Explosive – Tracking – Other

Any other info that you want to give:

My signature below certifies that the above statements are true to the best of my knowledge.

Applicants Signature: Date:

Print Name:

Checks payable to: SCPK9A

Mail Applications to:

SCPK9A P.O. Box 1514 Irmo, South Carolina 29063

(Adopted February 7, 2006)