Membership Form

FIFTH DISTRICT CITIZENS’ ADVISORY COUNCIL

MEMBERSHIP FORM
(print this form or join online)

5^th District Police Headquarters

1805 Bladensburg Road, NE

Washington, DC 20002

*NAME

*STREET ADDRESS

*APARTMENT/SUITE

*CITY/STATE/ZIP CODE

*TELEPHONE/CELL PHONE

*E-MAIL ADDRESS

IN CASE OF EMERGENCY, PLEASE CONTACT:

DUES:  $10.00    (Annually)

Please complete the Membership Form and bring it with you to the next meeting, or you may mail it to the Citizens’ Advisory Council at the 5^th Police District Headquarters (address listed above). You may include your dues with your membership form if you desire.  Please make your check Payable to:  5^th District CAC.

YOU WILL RECEIVE YOUR REGISTRATION CARD AT THE NEXT MEETING YOU ATTEND.