MISSISSIPPI LAW ENFORCEMENT OFFICERS' ASSOCIATION

131 NORTH FRONT STREET

SENATOBIA, MS 38668

Official Application for Membership

I hereby transmit my annual membership dues of $35 in the Mississippi Law Enforcement Officers’ Association.

Name:	______________________________________	Date of Birth: _________________

Department: _________________________________	Title: ________________________

Email: _____________________________________	Phone: _______________________

Address: ____________________________	City: _____________	State: _______ Zip: ______

Beneficiary: _________________________	Relationship: _____________________________

Address: ____________________________ City: _____________	State: _______Zip:_______

________________________________________________

Signature of Applicant

Agencies paying dues for All their officers receive a discount ($20 per officer). Applicants who have passed their 50th birthday prior to joining are not eligible for death benefits. Mail Remittance to:	MLEOA

Attn: Richard Chandler

131 NORTH FRONT ST.

SENATOBIA, MS 38668