MSFCA 2016 Membership Renewal and Registration
Mail check and paperwork to:
(NOTE NEW ADDRESS)
Minnesota State Fire Chiefs Association
2704 County Highway 10
Mounds View, MN 55112
Questions? Call 1-800-743-0911
Please Hand Print (Block letters) Type normal
Name of Department______
County ______Regional Association ______
FIRE CHIEF Active Primary Member
Name ______E-mail ______$93.00
Phone/Work ______Phone/Cell ______
Home Address ______
City ______State ______Zip ______
VOTING OFFICERS Active – Other Officer Member(s) (3 Bugles or more)
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City ______State ______Zip ______
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
NON-VOTING OFFICERS Associate Members - Captain, Lieutenant, Agency Members…)
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City or Town ______State ______Zip ______
ASSOCIATE MEMBERS (Non-voting- Captain, Lieutenant, Agency Members…) con’t
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City or Town ______State ______Zip ______
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City or Town ______State ______Zip ______
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City or Town ______State ______Zip ______
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City or Town ______State ______Zip ______
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City or Town ______State ______Zip ______
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City or Town ______State ______Zip ______
Name ______Rank ______$57.00
Phone ______E-mail ______
Home Address ______
City or Town ______State ______Zip ______
RETIRED CHIEF or other RETIRED OFFICERS
Name ______Organization______$57.00
Phone ______E-mail ______
Home Address ______
City or Town ______State ______Zip ______
MAGAZINE SUBSCRIBERS:
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
MAGAZINE SUBSCRIBERS Con’t…
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
Name ______$25.00
Phone ______E-mail ______
Home Address ______
City______State ______Zip ______
NEW - FIRE DEPARTMENT ADMINISTRATIVE CONTACT
Name ______Title ______$0.00
Phone ______E-mail ______
Address ______
City or Town ______State ______Zip ______
TOTAL ______
PAYMENT OPTIONS:Credit Card - call the office 800-743-0911
Invoice DepartmentP.O. Number ______
Payment Enclosed
Send the Renewal/Registration with payment to:MSFCA, 2704 County Highway 10, Mounds View,MN 55112
Thank you!