Membership

NAME: _____________________________________

TITLE:_______________

SSN:______-_______-_________

D.O.B. ___________________________

SEX:_____  HT:_________  WT:________  EYES:__________

HAIR:__________

HOME ADDRESS:

___________________________________________

CITY, STATE, ZIP:

___________________________________________

HOME PHONE: (______) ______________

WORK PHONE: (_____) ______________

EMAIL ADDRESS (optional):

__________________________________

LAW ENFORCEMENT AGENCY (if applicable):

_____________BADGE #________

* Make check out to Kearny Martial Arts for $30
* Send 2 headshot photos
* Send Martial Art certifications and documents for your file

As a member of the Police Tactics Instructors of America I promise to uphold the highest standards of integrity and honor and will uphold the constitution and by-laws of the organization. I also certify that the statements written on this application are true.

SIGNATURE: ____________________________

DATE:__________________

Initial Application o

Fill out the form and send your check of $30.00 along with your documents of instructor certification to: