"*" indicates required fields Agency InformationName of Agency*Head of Agency* First Last Head of Agency Title*Email* Phone*Agency Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is Head of Agency's REQUIRED TPCA Membership current?* Yes If no, visit TPCA’s Membership website to join.Agency Program Manager InformationAgency Program Manager* First Last Agency Program Manager Email* Agency Program Manager Phone*TPCA Region*Find your region at: www.tml.org/234/Map-OAicers# of Sworn Officers 1-10 – $600 11-19 – $750 20-25 – $1,000 26-50 – $2,000 51-100 – $2,500 101-200 – $3,000 201 or more – $3,500 # of Non-Sworn Officers*# Total Personnel*Use TML Risk Pool for Liability or WC?* Yes No Has the Head of Agency attended the required Training in person or online?* Yes No If yes, please provide the date of training the Head of Agency attended.Has the Agency Program Manager attended the required Training in person or online?* Yes No If yes, please provide the date of training the Agency Program Manager attended.Application Agreement*(Initials)Head of Agency's Electronic Signature*Today's Date* MM slash DD slash YYYY PaymentTotal Payment Method Online/Credit Card Invoice/Check This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card Δ
