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| Full Name: ________________________________________ | Spouse: _________________ |
| Address: _________________________________________ | Phone: __________________ |
| City, Province, Postal Code: ___________________________________________________ | |
| Agency name and Address: ____________________________________________________ | |
| City, Province, Postal Code: ___________________________________________________ | |
| Present Assignment: _________________________________ | Phone: __________________ |
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I BELIEVE THAT JESUS CHRIST IS THE ETERNAL SON OF GOD AND I HAVE RECEIVED HIM AS MY PERSONAL LORD AND SAVIOUR.
Please check all that apply
I am an Active Officer (Police, Correctional, Custom, Excise, Conservation, Justice, (as defined by the Criminal Code) and I request Regular Membership with full voting privileges.
I am a retired Peace Officer (minimum of 5 years service) and I request Regular Membership with full voting privileges.
I am the spouse of an Active or Retired Peace Officer who is or has been a member of FCPO (Canada) [as described above] and I request Associate Membership with full voting privileges.
I request Associate Membership, I understand that this does not include voting or office privileges (Spouse of non FCPO member, Auxiliary Officers and others with an interest in promoting the aims of FCPO Canada).
| Today's Date: ________________ | Signature: ___________________________________ |
| Spouse signature if husband and wife are both applying: | Signature: ___________________________________ |
You may apply via online form to be processed quicker, however all applicants must submit a hard copy of the application by printing this one, completing it, signing it and faxing or mailing it to the number/address below. FCPO Canada must have a signed copy on file for all members. Mailing Address: 73 Devonshire Ave,
Tillsonburg, Ontario, N4G 5C3
Telephone: (519) 842-4055 Fax: (519) 842-6107
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