fillable by nuhman10


									                        EMERALD SOCIETY OF WISCONSIN

Response to this form is purely voluntary. The information requested will be used in a
directory distributed to Emerald Society members only. You will not be listed in the
directory unless you complete this form. You may complete the form partially leaving
those portions blank that you do not want published. This is a fillable form that can be
completed and emailed to

Last Name              First Name or Initial        Middle Name or Initial    Suffix

Email Address                     Membership (Regular, Associate, Special or Honorary)

Name You Prefer (James, Jim, Skip, etc.)            Your Spouse’s Preferred Name

Law Enforcement Agency (if applicable)            Title, Position or Rank (include retired)

Home Address, Number and Street                   City, State and ZIP Code

Home Telephone Number         Check if Unlisted      Work Telephone Number

Check one:           This is a new entry.
                     This is a change, update or correction.

Signature                               Date

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