PLEASE PRINT OUT THIS FORM, FILL IT OUT AND
SEND WITH A CHECK
TO THE ADDRESS BELOW
Last
Name_________________________
First______________________________
Address___________________________________________
Apt. # _____________
City_________________________________
State______ Zip(+4)_______-_______
Telephone #
(___)_______________________ Cell: ( )
_________________________
Rank
_________
D.O.B._____/_____/______
Date
Appointed to NYCTPD _____/_____/_____ (for regular
membership)
Date Retired
______/______/______
For Associate
membership: Name of Department
_________________________________
Date
Appointed
_____/_____/_____ Date
Retired
______/______/______
For
Associate Membership: PAID member
sponsoring :_____________________________
Email_____________________________________________________________________
If
you are sending a donation of $20 or more, please indicate if you would
like to get a challenge coin as our
thanks.
YES _______________ NO ____________
Lifetime Membership for those who are 75
years or older.
Dues
must have been paid for the 3 years prior to turning
75.
If eligible, please check here ____ and make sure you have
filled out your DOB above.
Type of
Retirement: ( )
Service
( ) Ordinary
Disability
(
) Accident Disability
( ) Vested
Beneficiary: $300 Death benefit payable to members who are
paid up for previous 3
years
(Note: Does not apply to Associate or Honorary
Membership)
Name____________________________________________________________
Relationship
to
Member__________________________________________________________
Address__________________________________________________________
City__________________________
State_______ Zip (+4)________-_______
Telephone:
(H)_____________________ (C) ____________________________
Dues are $40
Make checks payable to NYCRTPOA and
mail to:
NYC Ret. TPO Assoc.
PO Box 345
East Rockaway, NY
11518-0345
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