KANSAS SHERIFFS ASSOCIATION MEMBERSHIP APPLICATION
Kansas Sheriffs Association
P.O. Box 1853
Salina, Kansas 67402-1853		 785 827-2222
FAX 785 827-5215
Please Print or Type

Check one Sheriff $15.00 Check one Regular $15.00  Check one Honorary $20  Check one Business $40

Date _______________   


Last Name _________________________________________________


First Name _________________________________________


Title _______________________


Agency ___________________________________________________________________


Home Address ______________________________________________________________


County __________________________


City _____________________________________


State ________________  Zip __________________


Beneficiary _______________________________________________________


Address _____________________________________________________


City ________________________________  State ___________________


Zip _________________


Signature
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* Regular -- Deputy, Law Enforcement Officer, RR Police, Fish & Game, etc.