Membership

Norwalk Police Emerald Society, Inc.

Date__________________

I HEARBY APPLY FOR MEMBERSHIP in the NORWALK POLICE EMERALD SOCIETY, and make each of the following statements of facts, as personally known to me, intending that the Society rely upon the truthfulness of each in acting upon this application:

NAME: _____________________________________________________________

(PLEASE PRINT)

MAILING ADDRESS: _________________________________________________

PHONE: ______________________ E-MAIL: ______________________________

DEPARTMENT/AGENCY: _____________________________________________

RANK: _____________________________________________________________

MEMBERSHIP:                   REGULAR                                       ASSOCIATE

STATUS:           ACTIVE               RETIRED           OTHER THAN P/O

SHIRT SIZE: ____________________

If elected to membership, I agree to abide by the Norwalk Police Emerald Society By-Laws, and by all future amendments, modifications, and changes thereto.

SIGNATURE________________________________

(Please make check out to: NORWALK POLICE EMERALD SOCIETY & return to

Ofc. K. Haddy of the Norwalk Police Department, 1 Monroe St., Norwalk, CT. 06851)