Auxiliary Registration Form

Name*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

Mobile/Phone

Birth Date

MonthDayYear

Profession

Why are you joining the WVTA?

As a token of your auxiliary membership you will receive a WVTA Challenge Coin

Signature

Please note that by joining the West Virginia Troopers Association as an auxiliary member, you DO NOT gain the rights or privileges of a West Virginia State Trooper. You DO NOT have the ability or right to answer law enforcement questions or provide services of ANY KIND.

Respectfully, we ask that if you do not support law enforcement or our endeavors, you do not join our Association.

My Products

Auxiliary Membership Fee One year Membership

$50.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration