AUSTRALIAN SECTION
MEMBERSHIP APPLICATION
FOR APPLICANTS NOT ON EMAIL ONLY
(Please complete in BLOCK letters)
1. Salutation: (Other)
2. Last name:
Given names:Preferred / Nickname
3. Residential address: Suburb/Town: State: Postcode:
Postal address: Suburb/Town: State: Postcode:
4. Telephone (H) (W): Mobile:
E-mail (H): E-mail (W):
5. Date of birth: / / Place of birth: (Include country if born overseas)
6. Marital status: Partner’s name:
7. Particulars of police service or previous service
Serving:Retired: Resigned:
Name of Police Force/Service: Station (if current serving):
Date joined:/ / Date retired:/ / Date resigned:/ /
Police Number (if not serving, provide number at time of leaving)
Police Rank (if not serving, rank at time of leaving)
State previous IPA section, Region andmembership no. if applicable:
8. If not a serving member – give details of current employment status, name and address of employer:
or Nil Nature of duties performed :
9.Other information – hobbies, interests etc.
Special interests/hobbies: Specialist/academic qualifications:
I declare I now apply for Ordinary Foreign Associate Extraordinary membership of the International Police Association and I agree with the Aims and Objectives of the said association as laid down in the constitution and regulations and that I shall conform to such regulations as may be made by the said section. I will endeavour to further the work of the association by fulfilling the obligations of membership and will submit my membership renewal fee of $20.00 regularly before the 31st of December each year. I submit herewith my enrolment fee of $30.00 and membership subscription of $20.00, a total of $50.00.
Please indicate – I am am not interested in meeting entertaining hosting visitors from:
a) b) Other: ; Anywhere
Signature: ………………………………………………..……Date:
ORDINARY MEMBERSHIP: (a) any serving or retired police officer of any State, Territory or the Australian Federal Police. (b) any former police officer who has served in a Police Service and had left such Police Service in good standing. FOREIGN ASSOCIATE MEMBERSHIP may be open to serving or retired members of a Police Service where Sections of the Association do not yet exist. EXTRAORDINARY MEMBERSHIP may be granted to the spouse of a deceased member, upon application from such spouse through region for endorsement by the National Executive Council.
SPECIAL NOTE: Direct Debit is available from your financial institution. Contact your regionaltreasurer for BSB and Account details to save your having to remember to send off your subscription in December each year.
Complete this form and forward with payment to regional treasurer:
South Australia & Northern TerritoryMr Andrew Bowe
c/- Sturt CSIU, 333 Sturt Road
Bedford Park SA 5042 / Queensland
Mr Lorenzo Ricato
PO Box 16025
City East QLD 4002 / Victoria/Tasmania (incl. Albury/Wodonga)
Mr Peter Henry
PO Box 166
Pascoe Vale South VIC 3044
Western Australia
Mr Stuart Halligan
P.O. Box 754
INNALOO CITY WA 6918 / New South Wales
Mr Charles Buttrose
PO Box 86
Forestville NSW 2087 / A.C.T.
Mr Julian Taylor
PO Box 201
Belconnen ACT 2616
PNG, Singapore Fiji other Overseas Mr Lorenzo Ricato P.O. Box 16025 City East QLD 4002