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MEMBERSHIP APPLICATION |
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PLEASE PRINT OUT THIS PDF FORM, FILL IT OUT
AND SEND WITH A CHECK
Last
Name_________________________
First______________________________ Date
Appointed
_____/_____/_____ Date
Retired
______/______/______
For
Associate Membership: PAID member
sponsoring :_____________________________ DONATIONS ARE ALWAYS APPRECIATED
TO KEEP THIS ORGANIZATION GOING
If you are sending a donation of $20 or more, please
indicate if you would like to get a challenge coin as our
thanks. If eligible, please check here ____ and make sure you have
filled out your DOB above. Next of
kin: Name:____________________________________ Relationship:
_______________________ Address:
____________________________________________________________________ City:
__________________________________ State:_______
ZIP+4__________+_________ Telephone:
(
)_______________________ Cell: ( ) _____________________________
NYC Ret. TPO Assoc.
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