Membership Application

Name: ___________________________________ Dept. I.D. or Badge #: _________

Agency: ______________________________________________________________

Address: _____________________________________________________________

City: ___________________________________ State: ______ ZIP: _____________

Work Phone: _____________________ Alt Phone: ___________________________

E-mail: __________________________ Alt E-mail: ___________________________

KPOA member? Yes No How long have you been a Negotiator? ___________

Please list any specialized training or incidents that can be used for training:

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________________________________________________________________________________
________________________________________________________________________________
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Please include…

• Copy of your agency credentials showing your ID/Badge number
• Membership Application
• $15.00 Membership Dues (Checks payable to KAHN)

Mail to: Greg Harkrader

2115 Plymouth Road

Manhattan, Kansas 66503

Office: 785-565-0385

Cell: 785-410-4820

Received by: _______________________________ Date: __________________