Application for Membership

Name

First

Last

Business Name

Mailing Address

City

State

Zip

Work Phone

Home Phone

Email

Are you currently a member

YES

NO

Please mark your membership choice

Regular Membership: $100.00 paid annually

Life Membership: $1,000.00 single payment

Life Membership-installment-$250.00 per year for 4 consecutive years (Total $1,000.00)

Business Membership: $150.00 paid annually

Business Life Membership: $1,500.00 single payment

I ___________________________ , as a member of Tarrant County Blue, promise to pay $100.00 in the event of a death of any member of a Tarrant County law enforcement agency while in the line of duty. 100% of these proceeds will go to the survivors of that fallen officer.