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NRLO MEMBERSHIP
FORM
See Benefits for details on
Memberships
Print this page and mail
or fax or e-mail
P.O. Box 6505 San
Antonio, Texas 78209 FAX: (210) 804-2463 e-mail:
nrloa01@earthlink.net
OR USE THE "CONTACT NRLO" PAGE TO REQUEST
A FORM
NRLO Premium Membership - $43
yearly*
* Dues are
non-refundable
Please check and
fill in all blanks that
apply:
DATE
of application:
1New Member 1Renewal
Member
#:
1
$43
Yearly dues
1 $25 Special Dues
(W/O Insurance)
**************************************************************************************************************************************************************************
LAST
NAME:
FIRST/MIDDLE:
D.O.B.
(YY/MM/DD):
**************************************************************************************************************************************************************************
MAIL
ADDRESS:
CITY:
STATE:
ZIP:
**************************************************************************************************************************************************************************
TITLE/RANK:
1Regular 1Reserve/Auxiliary 1Other:
Date
Sworn:
**************************************************************************************************************************************************************************
HOME
PHONE: (
)
WORK PHONE: (
)
DEPARTMENT PHONE: (
)
**************************************************************************************************************************************************************************
PERSONAL
E-MAIL:
BUSINESS
E-MAIL:
PERSONAL FAX: (
)
**************************************************************************************************************************************************************************
Full-time Job Description (if you are a
Reserve):
**************************************************************************************************************************************************************************
Department:
Name of 1Sheriff 1Chief of Police 1Other:
**************************************************************************************************************************************************************************
Dept./
Address/City/Zip:
#Reserves:
#Regulars:
**************************************************************************************************************************************************************************
Unit
Leader Title/Name: 1 Liaison 1Cmdr.
1Pres.
1Chief
1Other:
**************************************************************************************************************************************************************************
TRAINING:
Total Hrs.: Basic
Hrs.: Intermediate
Hrs.: Advanced
Hrs.: In-House Training
Hrs.: /
(Wk)(Mo)(Yr) Other:
**************************************************************************************************************************************************************************
Comments
on
Training:
**************************************************************************************************************************************************************************
AUTHORITY/BOARD which
qualifies and certifies
Reserves:
**************************************************************************************************************************************************************************
NOTE: Beneficiary names and addresses
must be on file in NRLO's Computer Records; please supply
information
below:
INSURANCE BENEFICIARY
NAME:
RELATIONSHIP TO
INSURED:
**************************************************************************************************************************************************************************
BENEFICIARY
ADDRESS/CITY/STATE/ZIP:
PHONE: (
)
**************************************************************************************************************************************************************************
REMARKS
/ (Example: "How Often and Where your Unit
meets"):
**************************************************************************************************************************************************************************
Insurance coverage effective on receipt of
payment.
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