REQUEST FOR RETIREMENT BENEFITSColorado Wildlife Employees Protective Association Name * First Name Last Name Title * Email * 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 Date of Retirement * MM DD YYYY Request for Benefits I am making an application to the Board of Directors of the Colorado Wildlife Employees Protective Association for: Payment of One Thousand Dollars ($1,000) Sterling silver Colorado Wildlife Officer buckle with badge number and remaining price difference in payment to equal One Thousand Dollars ($1,000) in value (price of buckle varies depending on current market price of silver) Thank you!