LJOA MEMBERSHIP APPLICATION 2012

NAME: __________________________________________

ADDRESS: __________________________________________

__________________________________________

AGENCY __________________________________________

AGENCY ADDRESS__________________________________________

__________________________________________

EMAIL ADDRESS ______________________@__________________

FEES FOR ACTIVE OR ASSOCIATE ARE………….. $ 20.00

PLEASE CHECK MEMBERSHIP TYPE YOU WISH TO JOIN:

ACTIVE________ ASSOCIATE _________ PAST PRESIDENT ______

**IF YOU ARE A PAST PRESIDENT PLEASE PROVIDE US WITH A CURRENT ADDRESS SO WE MAY KEEP IN TOUCH WITH YOU. **

ALL INFORMATION WILL BE KEPT CONDIENTIAL

Will you be attending this years conference YES NO (CIRCLE ONE)

PLEASE MAIL APPLICATION TO:

Louisiana Juvenile Officer's Association

Sgt. Kim Verret
P. O. Box 195
Perry, La. 70575
Phone 337-652-6143/Fax 337-893-8738

Also you may register at the conference.