NLOA Application

First Name (required):

Last Name (required):

Your Email (required):

Home Address:

Home Phone Number:

Mobile Number:

Date of Birth:

Last 4 SS#:

Religion:

Title/Rank:

Facility/PCT:

Tour:

Squad:

Seniority Date:

Shield#:

Tax Reg./Item #:

Annual Membership Dues:
Please indicate type of membership you prefer. You will be contacted by one of the Board Members about making payment.

Regular Membership: $25.00 Law Enforcement Civilian Member 

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