All Fields Marked (*) Must be Entered!

Select your purpose for submitting this form:

  Selcet Purpose Apply for PSTP Membership Request Change of Postion Change My Information Request Leave of Absence Return from LOA Return from ELOA Resign my Postion Resign from PSTP.org Re-Apply to PSTP.org

Today's date is: (select below)

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Please provide the following information about yourself:

First Name	*
Middle Name
Last Name	*
Title or Position
E-mail Address	* (Your e-mail address assigned to you by your ISP)
Alternate E-Mail Address	Note: PSTP.org does not accept the use of Unverifiable addresses such as, free accounts,  hotmail, yahoo, etc. as an alternate email address.
Postal Address	*
City	*
State / Province	*
Postal Code (Zip)	*
Country of Residence:	*
Telephone Number:

Are you an Adult or Minor in your Country of residence?		Select One Adult Minor  *
Instant Message Information
MSN			Ok to pass out?  yes no
Yahoo			Ok to pass out?  yes no
ICQ			Ok to pass out?  yes no
AOL			Ok to pass out?  yes no
MIRC			Ok to pass out?  yes no
Are you currently an active staff member of any of our departments?			Select Yes or No NO YES *
If so, what is your ID #
Select the Department you wish to work in			Select One Administration Personnel Marketing International Relations Public Relations Operations Communications Scam Patrol Technical Service IRC Services Web Services IS-IA
Number of years you have been on the Internet			Select one 1 - 3 years 3 - 5 years 5 years or more 10 years or more 15 years or more Over 20 Years *
Select hours you wish to contribute each week			Select One 5-10 11-20 21-30 31-40 Any Hours Necessary *

Please tell us more about yourself and your reasons for making this application *

All information is held in complete confidence and will not be released to any 3rd parties.

Thank you for submitting your application to Public Safety Task Patrol
Staff.