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Last Name:_______________________________ First Name:______________________________ Middle:_____________

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LERMA TAX ID# 38-3190154

AGENCY MEMBERSHIP DUES ARE $35.00 PER YEAR. TO HELP UPDATE OUR RECORDS, PLEASE COMPLETE THE ABOVE INFORMATION AND RETURN TO TREASURER, Kathy Bragg.

PLEASE RETURN TO: Kathy Bragg, Treasurer Three Rivers Police Department 333 W. Michigan Avenue Three Rivers, MI 49093 TELEPHONE: (269) 278-1235 FAX NUMBER: (269) 278-3195