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 EnforcementCivilian Member

    captcha
    Please type the text/numbers from above: