Name:  ____________________________________________________________________
As you wish it to appear on your certificate and in the directory.

Title:  _____________________________________________________________________
[  ] Active  [  ] Retired

Organization: _______________________________________________________________

Important: Check which address you wish mail to be sent but please include info on both.

[  ]  Business Street Address:  _________________________________________________

City:  _______________________________   State:  ____________  Zip: _____________

Business Phone:  ____________________________________________________________

Business E-mail:  ____________________________________________________________

[  ]  Home Street Address:  ___________________________________________________

City:  ________________________________  State:  ____________  Zip:  ____________

Home Phone:  _______________________________________________________________

Home E-mail:  _______________________________________________________________

Job Description and Areas of Expertise:  _________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Length of time in current position:  ____________________________________________

Length of time in law enforcement: ____________________________________________

Name of VHIA sponsoring member: _____________________________________________



PRINT THIS PAGE and then...
Mail your completed application form and check (made payable to VHIA) to:
VHIA
P.O. Box 317
Woodbridge, VA. 22191
Annual Dues:  (Indicate One)
_______________    $25.00    Active Membership
_______________    $25.00    Associate Member
_______________    $75.00    Charter Membership  (includes 1st year dues of $25.00)