APPLICATION FOR MEMBERSHIP Colorado Wildlife Employees Protective Association Name * First Name Last Name Email * If you would like to receive legislative updates please provide a personal email address (optional) Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Initial Date of Employment MM DD YYYY Title * Station * Beneficiary 1 Name * First Name Last Name Relationship Beneficiary 2 Name First Name Last Name Relationship Select Membership Level * Membership Only - $11.00/Month Membership and Legal Defense Coverage - $28.00/Month Initiation Fee Acknowledgement * I understand that I will be charged a one time initiation fee of $12.00 Acknowledgment * I hereby state there are no known lawsuits or obligations pending against me at this time that could or may involve the Colorado Wildlife Employees Protective Association. I understand that protective benefits are possible only for instances governed by the bylaws of the Association and/or optional Legal Defense Coverage, and are effective only after the date of acceptance of my membership by Board vote. Thank you!