______________________________________________________________________________

MONTGOMERY COUNTY BLACK

LAW ENFORCEMENT OFFICERS ASSOCIATION

                                   _________________________________________________________

P O Box 123, Bridgeport PA 19405

(877) 861-7507 toll free

E-mail: info@mcbleoa.net

APPLICATION FOR ASSOCIATE MEMBERSHIP

                                                                                                            DATE:__________________

I, the undersigned, certifying that I am an American citizen 18 years of age or older and of good moral character, do hereby apply for admission as an associate member of the MONTGOMERY COUNTY BLACK LAW ENFORCEMENT OFFICERS ASSOCIATION.  In support thereof, I solemnly affirm on my honor that the personal information set forth below is true and correct and that nothing has been withheld for purpose of evasion.

If elected to membership, I promise to abide by the by-laws and all rules and regulations of the association by which I hereby agree to be bound; to pay all annual dues regularly fixed by the association, and to conduct myself at all times in such a manner as not to bring reproach upon the ASSOCIATION, or myself.  I also agree that violation of this pledge shall result in forfeiture of membership and all of its privileges.  Associate membership cost $25 per year.

I also agree to support the M.C.B.L.E.O.A. in all lawful endeavors, which it may engage in for the enhancement of police efficiency and for the general welfare of the police officers, their families and the communities that are served throughout our county, our state, and our nation.

NAME___________________________________   HOME PHONE (      )______-__________

ADDRESS____________________________________________________________________

CITY__________________________________   STATE_______   ZIP CODE______________

EMPLOYER______________________________________    TITLE_____________________

EMPLOYER’S ADDRESS________________________________________________________

CITY_________________________________ STATE________ ZIP CODE _______________

EMAIL: _____________________________________________________________________

EMPLOYERS PHONE NUMBER (      ) ___________-______________________

PROPOSED BY______________________________      DATE__________________________

ACCEPT__________________  REJECT____________________