Combined Lifetime Member Application

Pennsylvania Eastern Chapter, FBI National Academy Associates
LIFETIME MEMBERSHIP APPLICATION
This form needs to be completed in its entirety in order to request lifetime membership with the Eastern Pennsylvania FBINAA Chapter. Lifetime membership will be offered as long as the FBINAA Eastern PA Chapter is financially sound. In order to be considered for lifetime membership, you must have been a member in good standing of the FBINAA Eastern PA Chapter for twenty-five consecutive years and retired from full time law enforcement. Once you have completed this form it will be submitted to the FBINAA Eastern PA Executive Board for review.

The application will be taken under consideration at the next Executive Board meeting, and you will be notified. The Executive Board as the right to reject any and all applications or to eliminate this program at any time it is deemed necessary.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
NA Session #
Are you currently designated a Life Member of the Pennsylvania Eastern Chapter of the FBINAA?

YesNo
Year Graduated blanks . Number of years you have been a dues paying member blank.
Police Department Retired from:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years of Service blanks. Rank at Retirement blank.
Are you currently employed in law enforcement?

YesNoFull TimePart Time
Name of New Department
Address of New Department

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years of service fromto.
Do you wish to remain a Life Member of the Pennsylvania Eastern Chapter of the FBINAA?

YesNo
Today's Date

MonthDayYear
Date
Should be Empty:

Pennsylvania Eastern Chapter, FBI National Academy Associates

LIFETIME MEMBERSHIP APPLICATION