CPCA Membership Application Please print or type

Name _______________________________________________________ Last First Middle Business Title/Position ___________________________________________

Date Appointed to Current Position _________________________________

Month Year Employer _____________________________________________

Business Address ______________________________________________ Street ____________________________________________________
City State Zip
Business Phone: ________________________________________________ Business FAX: _________________________________________________ Home Address _________________________________________________ Street _______________________________________________________ City State Zip Home Phone __________________________________________________ E-Mail Address ________________________________________________ Web site: _____________________________________________________ Preferred Mailing Address:   [  ] Business [ ] Home Type of Membership Requested: [ ] Active [ ] Life [ ] Associate [ ] Senior Management ____________________________________________________________ Sponsoring Chief or Executive Director’s approval Please Return To: Connecticut Police Chiefs Association 342 North Main Street West Hartford, CT 06117-2507 (860) 586-7506; FAX (860) 586-7550 E-Mail: info@cpcanet.org [ ] I have read and support the Association’s Code of Ethics.

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