Illinois Tactical Officers Association

Membership/Renewal Application

Pay by Credit Card/Department or Personal Check

New Member

Renewing Member

*

First Name *

M.I.

Last Name *

Suffix

Rank/Title *

Agency Name (if not applicable enter HOME) *

Agency Address (if not applicable enter home address) *

Address Line 2

City *

State *

Zip Code *

Department Phone ONLY *

Personal Phone - OPTIONAL

Note: If you are completing this form for someone else, please enter in the registered person's correct email address. Otherwise, he/she will not receive ITOA Notifications, Confirmation Letter or ITOA News magazine.

Department Email Address ONLY *

Personal Email Address - OPTIONAL

Referred by

Specialized Team *

Other Specialized Team *

Membership Category (select one) *

Category of Service (select one) *

Basic Police Training (date & location)

Name of Supervisor (to verify assignment)

Supervisor's Telephone Number

Areas of Specialty (firearms, rappeling, tactics, etc.)

I affirm that the above listed information is true and accurate.

*

I authorize the Illinois Tactical Officers Association to contact my agency to verify the above information.

*

Payment

Membership Fee is $40.00

Pay by: *

Charge

Personal Check (You will be invoiced) -- Use the pay by check option on the next page.

Department Check/Purchase Order (Your PD will be invoiced) -- Use the pay by check option on the next page.

Name on Credit Card *

Purchase Order Number *

Email address of the person responsible for payment *

Current Total:

$0.00