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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