MEMBERSHIP FORM
Please complete this form and return it to us with a check made payable to the Kansas Sheriff's Association. In return, we will mail you a membership card.

In the event of death, in the line of duty, a full time law enforcement's Officers  beneficiary  will receive a cash benefit of $5000.00.  Off duty death benefit is $1000.00

Department or Sheriff's office  you work for:____________________________
Sheriff .............................$15.00
Undersheriff .................$15.00
Deputy ..............................$15.00
Part-time Officer. . . . $15.00
Others ..............................$15.00    

Honorary membership$20.00 ( no death benefits)          

Business membership  $40.00 ( no death benefits)
Name (please print)_________________________________
Date_____________
Address_______________City____________State______Zip___

Full-time Officer, in the event of my death during this calendar year, I hereby designate ___________________________as my benefit survivor.
Beneficiary’s name ___________________________________

Address______________City___________State______Zip____________

Kansas Sheriffs Association Box 1853
Salina, Kansas 67402-1853
PLEASE INDICATE CHANGES ON ADDRESS LABEL