Name:                                               Title:               Date:                         

Department:                                                                                              

Mailing Address:                                                                                                                                  

City:                                         State:              Zip Code:                        

Email Address:                                                                                                 

Phone:                                             Fax:                                                

Department Website Address:                                                           

Active and Sustaining Membership Dues are $50.00 per year.

Associate Mamber Dues are 80.00 per year.

$5.00 additional if paid after April 15.

Keep this portion for your records

                                                  _{CUT ON LINE}                                                             

Membership  Application

Name:                                               Title:               Date:                         

Department:                                                                                              

Mailing Address:                                                                                     

City:                                         State:              Zip Code:                        

Email Address:                                                                                      

Phone:                                        Fax:                                                 

Department Website Address:                                                         

New Member:                      Membership Renewal:                   

Send this portion and remittance to:

U.P. Fire Chief’s Association