Member Update Form Submit Date:

Last Name: First Name:

Rank/Title: Department:

Work Address: City: State: Zip:

Work Phone: Fax: Email:

School Name

Middle School High School or Other

Do you serve as SRO for more than one school? Yes No

My information change relates to: Select One Retiring (during current or next membership year) Rank/Title change Department change Work address, phone and/or fax change Other (as explained under Comments) Email address change Various changes (please list changes under Comments)

Comments:

(If Applicable) Retiring: Select One Retiring in current membership year Retiring in next membership year Other - please see my notes in the Comments section