The Secretary

Retired Police Association of NSW Inc.

PO Box 354

WINGHAM  NSW  2429

Dear Sir,

I wish to become a Social member of the Retired Police Association of NSW Inc.

*        My annual membership fee of $18.20 is enclosed.

My particulars are as follows:

Surname:       ___________________________________

First Names:   ___________________________________

Address:        ___________________________________

Suburb:         ___________________________________

Postcode:      ___________________________________

Phone No:      ___________________________________

Mobile:          ___________________________________

D.O.B.:          ___________________________________

Occupation:   ___________________________________

Partner:        ___________________________________

E-mail: ___________________________________

TO BE COMPLETED BY TWO FULL FINANCIAL MEMBERS OF THE RPA.

We, the undersigned, propose: -

__________________________________________________

as a Social member of the Retired Police Association of NSW Inc.

Proposed by:  __________________________________________________________________________

          Name                               Signature                          Date

Proposed by:  __________________________________________________________________________

                   Name                               Signature                          Date