Date:____________ New___ Renewal___
I herewith transmit annual dues for membership as follows:

___ Active($125)
___ Retired Active($62.50)
___ Associate($100)
___ Supportive($75)
___ 100 Club'($100)
___ Corporate($500)

Note: 2^nd Active member from same dept. pays $75.00

Name____________________________________________________________

Rank/Title________________________________ Division__________________

Agency Name_____________________________________________________

Agency Address___________________________________________________

City__________________________________ State______ Zip______________

Business phone(____)_______________ Fax number(____)________________

Home Address_____________________________________________________

City__________________________________ State______ Zip______________

Spouse's Name_______________________ Home Phone___________________

Sponsor-Member # (MPCA Board requires a recommendation from a current member)
________________________________

Office Use Only

Type Membership_____________________ Member No.______________ Year______
Dues Paid_________ Date __________ Received by____________________________

Print out and return to MPCA

Fax to (573) 636-6634
or
Mail to:
MPCA
600 E. Capitol Ave.
Jefferson City, MO 65101
Questions? Call (573) 636-5444 or by email: slineback@mopca.com