Fiscal Year: Jan 1,_200__ -- December 31, 200__
NAME OF CRIME STOPPERS PROGRAM_______________________________________________
NAME OF SCHOOL PROGRAM OR DISTRICT__________________________________________
ADDRESS_____________________CITY____________STATE/PROVINCE________COUNTRY____
TEL: ( ) - FAX: ( ) - E-MAIL:___________________WEB URL:_____________________
1. SPONSORED BY (Name of local Crime Stoppers Program)__________________________________
RECOGNIZES: ( Name of School Program or District)_______________________________________
SCHOOL PROGRAM ADMINISTRATOR_____________________________________________
STUDENT CRIME STOPPERS PROGRAM CHAIR___________________________________
To be the sole administrating and governing body of the Scholastic Crime Stoppers Program in:
NAME OF SCHOOL OR DISTRICT___________________________________________________
IF APPLICATION IS FOR A DISTRICT. NUMBER OF SCHOOLS IN DISTRICT________________
( Attach separate sheet showing names of schools and addresses)
2. NAME OF SCHOOL/DISTRICT____________________hereby recognizes by applying for membership and acceptance by Crime Stoppers International, Inc. they must abide by all guidelines established by C.S.I with respect to the Scholastic Crime Stoppers Program.
3. This Membership Application is subject to review and revocation by the Membership Committee and based on the Policies and Procedures of Crime Stoppers International, Inc.
SPONSOR PROGRAM___________________PRINCIPAL/SUPERINTENDENT________________
Signed: Chair Local Program:____________________________
Signed: School or District: ____________________________
FOR CRIME STOPPERS INTERNATIONAL USE ONLY
APPROVED----DENIED_______________________DATE_________MEMBERSHIP NBR________
Membership Committee Chair:____________________________
DUES RECEIVED: ( YES) (NO) DATE___________AMOUNT PAID______CHECK NBR_____
ANNUAL MEMBERSHIP FEE STRUCTURE
CATEGORY I. INDIVIDUAL SCHOOL: US $ 50.00
Mail Completed Application and Check for Dues to:
Scholastic Crime Stoppers Membership