BIRTH DATE_____/____/____     ANNUAL DUES ARE $25.00     CHECK #_______

APPOINTMENT DATE _____/_____/_____ RETIREMENT DATE _____/_____/____

PENSION #(REQ'D) _________ LAST COMMAND________ LAST RANK________

LIST ALL PREVIOUS COMMANDS_______________________________________

__________________________________________________________________

ASSOCIATE MEMBERS

LAW ENFORCEMENT AGENCY_____________________ RANK_______________

LAW ENFORCEMENT TELEPHONE (____)_________________________________

RETIRED (__) ACTIVE (__)         MILITARY (___) ACTIVE   (___) RETIRED

I declare my desire for membership in the Northeast Florida 10-13 club
and to abide by the rules and constitution of the club. Furthermore, I
promise to remain a member in good standing and to submit my yearly
dues on or about the 1st of January. By affixing my signature below,
I attest to the above as being true and to the best of my knowledge.

Signature_____________________________________ Date _____/_____/_____

LIFETIME MEMBERS PAY $5.00 YEARLY

MAKE CHECKS PAYABLE TO:
NE FL 10-13
P.O. BOX 352601
PALM COAST, FL 32135-2601