ASSOCIATION OF FORMER AGENTS OF



ASSOCIATION OF FORMER AGENTS OF THE U. S. SECRET SERVICE

APPLICATION FOR MEMBERSHIP

Full Name: _______________________________________ __ Nickname: _________

(First) (Middle) (Last)

Date of Birth: __________________ Spouse Name: _________________

(Month) (Day) (Year)

Street Address: _________________________________________________

City: __________________________________ State: _______ Zip: _________-________

Home Telephone: (____) ____- _________ Home Fax: (____) ____ - _________

Home E-Mail Address: _____________________________________________

USSS Career: Date From: ____________________ Date To: _____________________

Last Secret Service Office: _________________________________________

Current Employer: ________________ Your Title: _______________

Address: _______________________________________________ __

City: __________________________________ State: _______ Zip: _________-_______

Work Telephone: (____) ____ _________ Work Fax: (____) ____ _________

Work E-Mail Address: _____________________________________________

To which e-mail address do you prefer AFAUSSS messages be sent? __Work (or) __ Home

Check below:

___ Regular Member- Retired Agent $75/year

___ Regular Member - Former Agent $75/year

___ Associate Member (Active Agent) $25/year

___ Affiliate Member (Active/Retired/Former Employee) $25/year

First Time Members - Free for Balance of Current Year (July 1 – June 30)

___ Widow/Widowers of Members Free

___ Life Member (Regular members, 75 years old or older) Free

I certify that I meet all of the requirements of the current by-laws of AFAUSSS for membership. Membership shall be open to persons of good character who have served with due fidelity within the U.S. Secret Service for at least one year, as well as widows/widowers of Members. I approve AFAUSSS checking my background.

___________________________________ ____________________

APPLICANT’S SIGNATURE Date

Send this Application and check (if required), payable to AFAUSSS to:

AFAUSSS, 525 SW 5th Street, Suite A, Des Moines, IA 50309-4501

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