Florida Highway Patrol
Command Officers Association, Inc.
MEMBERSHIP APPLICATION
       
       
(Last Name) (First Name)   (M.I.)
       
*Required for Insurance Click to select date.
Social Security Number Date of Birth Gender
       
(Address) (City) (State) (Zip Code)
       
(Mailing Address, if different) (City) (State) (Zip Code)
       
 
    (Home Phone #) (Work Phone #) (Ext)  
       
     
E-Mail Address      
       
(Check One)      
Active Duty FHP Command Officer (Dues/$120.00 per year)    
Retired FHP Command Officer      
       
Click to select date. Click to select date.
(Rank) (Date of Current Rank) (Employment Date)
       
(Troop) (District) (Retirement Date)
    (if applicable)
       
I CERTIFY THAT I AM CURRENTLY EMPLOYED AS A COMMAND OFFICER OF THE FLORIDA HIGHWAY PATROL; OR A RETIRED COMMAND OFFICER OF THE FLORIDA HIGHWAY PATROL.
       
       
 
(Signature)   (Date)
       
 
Revised 09/09