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
_________Date Appointed to NYCTPD _____/_____/_____ (for regular
membership)
For Associate membership:
Name of Department
____________________________
Date
Retired
______/______/______
D.O.B._____/_____/______
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 $30
Make checks payable to NYCRTPOA and
mail to:
NYC Ret. TPO
Assoc.
PO Box 345
East Rockaway, NY 11518-0345
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