P. O. Box 253,  Princeton, MA 01541-0253

www.MLEFIAA.org

E-mail:  SECRETARY@MLEFIAA.org

FOR OFFICE USE ONLY

DATE RECEIVED:             

     PAID BY:             

ID # ASSIGNED:             

MEMBERSHIP APPLICATION

PLEASE PRINT OR TYPE ALL REQUESTED INFORMATION CLEARLY

DATE OF APPLICATION: _________________________________RECOMMENDED BY: _________________________________

MEMBERSHIP CLASS APPLIED FOR:   ____  ACTIVE      ____  ASSOCIATE  (see MEMBER INFO page for membership requirements)

FIRST NAME:  _______________________   M.I.:_______   LAST NAME:  _______________________________   RANK/TITLE: ___________

DEPARTMENT or ORGANIZATION:  __________________________________________________________________________________    

AGENCY STREET ADDRESS:  _______________________________________________  

AGENCY CITY/TOWN:  _____________________________________________________ 

STATE:  _______   ZIP+4:  ______________________        PHONE:  __________________________    FAX:  _______________________

HOME STREET ADDRESS:  _________________________________________________

HOME CITY/TOWN:  _______________________________________________________

STATE:  _______    ZIP+4:  ______________________       PHONE:  __________________________  E-MAIL:  ______________________

LIST COURSES ATTENDED (MCJTC, FBI, NRA, MILITARY, S&W, etc.)

ATTACH COPIES OF CERTIFICATES OF THE MOST RECENT INSTRUCTOR / ARMORER SCHOOL(S) ATTENDED

SPONSORING ORGANIZATIONCOURSE TITLE      MOST RECENT DATE

________________________________        _____________________________________________________         ____________________

________________________________        _____________________________________________________         ____________________

________________________________        _____________________________________________________         ____________________

________________________________        _____________________________________________________         ____________________

________________________________        _____________________________________________________         ____________________

INDICATE YEARS OF EXPERIENCE IN EACH CATAGORY BELOW

REVOLVERPISTOLSHOTGUNRIFLEGAS GUNSPECIAL WEAPONS*OTHER*

INSTRUCTOR________ _______________         ______        _______         __________       _______

ARMORER    ________ _______________         ______        _______                   __________                 _______

Please specifiy SPECIAL & OTHER WEAPONS here: 

________________________________________________________________________________________________________________

_______________________________________     ______________________________________

                                            Signature of Applicant             Signature of Agency or Organization Head

FORM 1W          

Copyright 2002  Massachusetts Law Enforcement Firearms Instructors' & Armorers' Association                                   REVISED 1/2002