Mississippi Law Enforcement Officers' Association
Official Application for Membership
I hereby transmit my Annual Membership Dues of $25.00 in the Mississippi Law Enforcement Officers Association for the year ________
NAME__________________________________________________________
DATE OF BIRTH_________________________________________________
DEPARTMENT__________________________________________________
TITLE__________________________________________________________
ADDRESS_______________________________________________________
(STREET)
_______________________________________________________________
(CITY) (COUNTY) (STATE) (ZIP)
PHONE NUMBER_________________________________________________
BENEFICIARY___________________________________________________
RELATIONSHIP__________________________________________________
Signature of
Applicant________________________________________________________
ANNUAL DUES $25.00
Applicants who have passed their 50th birthday are not eligible for death benefits.
MAIL REMITTANCE TO: CHARLIE SIMS, EXECUTIVE TREASURER
14 SOUTHGATE ROAD
HATTIESBURG, MS, 39401
