2022 Membership Application for C.L.I.A.
Application for membership into C.L.I.A.
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First Name: *
Full First Name
Last Name: *
Full Last Name
Middle Name or Initial *
Gregory or G.
Rank *
Deputy, Officer, Agent
Department or Agency *
Sheriff's Office, Police Department, Federal Agency
Street Address: *
EX: 123 ABC St
City and State: *
Anytown, Kansas (if out of country please give closest equivalent for mailing purposes)
Zip Code: *
If out of country please put down closest equivalent for zip code for mailing purposes
Work or Home Address: *
In Response To The Question Above
Telephone Number: *
Best Number To Reach The Applicant At
Work Or Home Number *
In Response To Question Above
Email Address *
Best Email To Reach Applicant At
Supervisor's Rank *
Sgt., Lt., Chief
Supervisor's Phone Number: *
Supervisor's Name *
Please enter your supervisor's full name
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