Department:

Last Name:_______________________________ First Name:______________________________ Middle:_____________

TITLE:

Address:

City: Zip:

EMAIL:

Phone: Fax:

LERMA TAX ID# 38-3190154

AGENCY MEMBERSHIP DUES ARE $35.00 PER YEAR. TO HELP UPDATE OUR RECORDS, PLEASE COMPLETE THE ABOVE INFORMATION AND RETURN TO TREASURER.

PLEASE RETURN TO: Carol Wright, Treasurer Troy Police Department 500 West Big Beaver Rd. Troy, MI 48084 TX: 248) 524-3440 FAX: 248) 524-1503