This form secured with banking level encryption for your protection and privacy
INSTRUCTIONS Please fill out the following form completely. ALL items are required. You will receive a copy of this application at the email address you provide.
First Name
Last Name
Email Address
Retype Email Address
Your Address
Street
City
State
Zip
Your Officer's Name
Law Enforcement Department
City & State
End of Watch Date
Was it a line of duty death?	Yes  No
Your relationship to the fallen Officer
Want help with (please explain)
Are you human? To help us avoid spambots, please answer the question below to show that you're a person and not a spam-bot What is 30 15 ?
A member of board of director will contact you and make a decision. All recipients agree to register with concerns of Police Survivors and stay at C.O.P.S. Hotels, arriving and leaving according to C.O.P.S. planned event dates. Recipients also must fly into Ronald Reagan National Airport DCA between 9 a.m. and 6 p.m. If arriving on any other date, any other airport, recipients will need to arrange transportation to hotel.