Membership Application
If interested in becoming a Region 20 member, copy the membership application below, fill it out and send it to the address at the bottom.
THE UNITED STATES POLICE CANINE ASSOCIATION, INC.
APPLICATION FOR MEMBERSHIP YEAR 20 __
DISTRICT #____ REGION # 20 IS THIS A DUAL MEMBERSHIP? _______
Name ___________________________________ Home Phone _____-_____-_________
Address __________________________________________ Date of Birth ____________
City ______________________________ State ___________________ Zip ___________
Police/Military/or Law Agency employed by: Full Address and Phone.
Agency _________________________________________________________________
Address _____________________________________ Phone _____-_____-__________
City ____________________________________ State _____________ Zip __________
Present Rank _______________________________ # Years Employed _____________
Position _____ Handler _____ Trainer ____ Administrator ____ Other ________________
Breed of Dog ____________________ Name __________________ Age ____________
Dog ____________________ Name __________________ Age ____________
Circle type of Work --- Patrol --- Narcotics --- Explosive --- Other_________
Circle type of Work --- Patrol --- Narcotics --- Explosive --- Other_________
Type of training course attended or type of training you have received up to the present time:
(Describe in brief)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Type of membership: ______ Renewal ______ New Membership
Regular _____ Associate _____ Honorary _____ Special _____
U.S.P.C.A. Certified National Judge: Yes ____ No ____
U.S.P.C.A. Certified Trainer: Yes ____ No ____ Level _____
For Regular or Associate Members:
Relationship _______________________________ of Beneficiary for Death Benefit.
Name ______________________________ Address _____________________________
State _____________________ Zip ______________ Phone _____-_____-___________
Please check that the application is filled out completely with signature. Forward with a $40.00
check (one year's dues, Jan 1 to Dec 31) made payable to the United States Police Canine
Association, Inc.
Date : _____________________ Signature __________________________________
Mail To:
USPCA REGION 20
JIM MINTON-SECRETARY
12345 ALAMEDA TRACE CIRCLE SUITE#114
AUSTIN, TX 78727