*Please Select One: NEW MEMBER   MEMBERSHIP RENEWAL

*Last Name *First Name M.I.  

*Home Address

*City *State *Zip Code  

*Telephone # Cell Phone # Pager #

*E-Mail Address

*Send Any Mail To My: Residence   E-Mail Address   Both

I Would Like To Volunteer For The Following Committee’s:

    Fund-Raiser   Safety Fair    Parade   Banquet

    Thanksgiving Meals   Operation Santa Claus    Giveaway's

*I Would Like To Be Contacted To Attend Other Organizations Banquets:

     Yes   No

ACTIVE/REGULAR/HONORARY MEMBERS Fill Out The Following Only

*Law Enforcement Agency

*Position/Title *Star/ID # Unit #

Work Phone #  

Note: It is the responsibility of the member to keep their information up to date by contacting the HISLEA Secretary, secretary@hislea.org,  and informing them of any changes to your information.  HISLEA cannot be responsible for any misdirected correspondence due to incorrect information.

rev 10/07