P. O. Box 11   Brimfield, MA  01010-0011
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:  

________________________________________________________________________________________________________________




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