BSPA Official Application for Membership
Are you interested in joining The Black Shield Police Association? All responses on this form will be confidential.

If you have any questions, please email us at info@theblackshield.org.
Email address *
What is your FIRST and LAST name? *
Your answer
What gender do you most closely identify with? *
What is your HOME address? (include CITY, STATE and ZIP CODE) *
Your answer
What is your phone number? *
Your answer
When is your birthday? *
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PUBLIC SAFETY AGENCY EMPLOYED
Please provide these details to the best of your ability.
Name of Agency *
Your answer
Agency Address *
Your answer
Unit or Department *
Your answer
Agency Phone Number *
Your answer
Date of Appointment or Hire *
MM
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DD
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YYYY
PERSONAL HISTORY
The following questions concern your own personal history. Please note that all answers will be kept confidential.
What is your current marital status? *
If married or engaged, what is your partner's name?
Your answer
Number of Children *
Your answer
Religion (if not religious, denote "non-religious") *
Your answer
If attending a house of worship, please denote name. *
Your answer
Hobbies, Skills or Trades *
Your answer
Which current/retired BSPA member recommended you for membership or would vouch for your membership? (If unsure or N/A, please state "unsure" or "N/A") *
Your answer
By checking this box, I am ensuring that all information is accurate to the best of my knowledge. *
Required
A copy of your responses will be emailed to the address you provided.
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