Date 

Month January February March April May June July August September October November December Select One      Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Select One      Year 2005 2006 2007 2008 Select One

Your Full Name (Jones, Peter) 

Type of Membership Regular Member Associate Member Corporate Associate Life Member Other Please choose one...

Title

Police Department/Agency (Sanford Police Department)

Agency Address (street #, street, city, state, zip)

Residence Address (street #, street, city, state, zip)

Send Mail To: (check one) Business  Residence

Business Phone

Email Address (jones@aol.com)

Place of Birth

Date of Birth

Name of Spouse (optional)

Education

Date elected or appointed to present office

Law Enforcement Experience (with approx. dates)

Have you previously been a member of the MCOPA (check one)
Yes  No

If so, when and where

Applicant's Initials (enter)

By entering your initials you certify that the information in this application is true and correct to the best of my knowledge and belief. Any false information or misstatement of fact could result in refusal of this application or removal from membership in the Maine Chiefs of Police Association.

Sponsor Name (must be sponsored by current member)

Sponsor Agency 

Sponsor City

All applicants must be sponsored & investigated by a current and regular member of the MCOPA. Sending and completing this application does not guarantee membership in the Maine Chiefs of Police Association.

  I have read and understand the above statement (please initial)