Name: _____________________________________________________________________________________________
Address: __________________________________________________________________________________________
City: _________________________________________________ State: ________ Zip: _____________________
Phone Number: ______________________________________________________
Occupation: _________________________________________________________
Sponsor: _____________________________________________________________
DUES OPTION (check which)
_______ ActivePolice/Firefighters ($15)
_______Pensioned Police/Firefighters (Payroll Deduction - $12)
_______Pensioned Police/Firefighters (Cash/Check - $15)
_______Civilian ($15)
After completing the application, mail to:
The Philadelphia Emerald Society
P.O. Box 2430
Philadelphia, PA 19147