MEMBERSHIP APPLICATION

 

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PLEASE PRINT OUT THIS PDF 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_____________________________________________________________________


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.
                                                            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

Next of kin:

Name:____________________________________ Relationship: _______________________

Address: ____________________________________________________________________

City: __________________________________ State:_______ ZIP+4__________+_________

Telephone: (       )_______________________ Cell: (       ) _____________________________


Dues are $40            Make checks payable to NYCRTPOA and mail to:

NYC Ret. TPO Assoc.
PO Box 345
East Rockaway, NY 11518-0345