Application for Agency Membership 

MEMBERSHIP IS VALID THROUGH 30-JUNE-2012

All training sessions  will be open to any interested personnel from your department as space allows.
Please indicate the name of one individual from your department that will be representing your department, have voting rights, and receive I.C.P.A mailings.

 Name:  _____________________________________________________________________________

 
Department or Business Name:  ___________________________________________________________

Mailing Address:  ______________________________________________________________________

City:  _______________________________________________   State:  ______  Zip:  _______________

Telephone:  _________________________________________________EXT. _____________________

 FAX Number: (optional)  ________________________________________________________________

 E-Mail Address:  ______________________________________________________________________

 AMOUNT DUE ..........................................................................................................................$100.00

Please mail completed application and check payable to:

Illinois Crime Prevention Association
 
Nathan E Roudez, ICPA Treasurer
c/o Riverdale Police Department

725 W. 138^th Street
Riverdale, IL  60827