Membership Application

Individual Membership

Single employee membership

$50.00 Quantity

Agency Membership

Agency memberhip covers all employees of the agency.

$300.00 Quantity

Total

Agency Name
Must be a current employee of a Local or Regional Jail.
New Member Name or Agency Point of Contact

First NameLast Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Information:
Any other comments or questions?
Declaration:

By submitting this form you are certifying that all information provided in this application is true and accurate to the best of your knowledge. You understand that membership approval is at the discretion of the association and may be subject to review.
Should be Empty:

Additional Information: