Application for Full Membership Name* First Middle Last Gender Male Female Job Title/Rank* Department* Date Entered County Service* MM slash DD slash YYYY County Employee Number* Last 4 digits of SSN* Place of Assignment* Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Phone*Cell Phone*Date of Birth* MM slash DD slash YYYY Personal Email (non-LASD)* I hereby apply for active membership in the Los Angeles County Professional Peace Officers Association. I authorize appropriate deductions from my County payroll warrant for payment of dues and other programs that I may select. I also authorize, at the discretion of the LACPPOA Board of Directors, the use of a portion of my dues for political action. (Political contributions are not tax deductible. For more details, call the PPOA office.) I certify that, at this time, I know of no investigation of me by my Department, nor am I involved in any civil proceeding as a result of my performance as a peace officer.Deduction Agency* Deduction Code* Monthly Membership Dues Deduction*Full PPOA membership is available only to classifications below. Amounts shown are monthly dues, based on 1% of top step salary plus FOP Legal Defense and $5 for additional political action. (Monthly dues as of 1/1/21) Unit 612 (Sheriff, D.A.) Unit 614 (Coroner/Sheriff) Unit 621 (Sheriff) Unit 631 (Coroner) Unit 632 (Coroner) Unit 995 (Captain/Commander) Unit 612 (Sheriff, D.A.) Dues* Sergeant (LASD) & above [$119.33] Sergeant (DA) & above [$119.33] Unit 614 (Coroner/Sheriff) Dues* Criminalist [$90.04] Criminalist Lab Technician [$63.93] Forensic ID Specialist I [$85.83] Forensic ID Specialist II [$101.61] Senior Criminalist [$117.74] Unit 621 (Sheriff) Dues* Civilian Investigator [$86.58] Court Services Specialist [$59.62] Crime Analyst [$84.72] Custody Assistant [$71.26] Law Enforcement Technician [$64.99] Public Response Dispatcher I [$64.87] Public Response Dispatcher II [$74.50] Public Response Dispatcher Specialist [$79.77] Security Assistant [$39.94] Security Officer [$57.25] Supervisor Public Response Dispatch [$81.85] Unit 631 (Coroner) Dues* Coroner Investigator [$90.44] Coroner Investigator Trainee [$82.20] Unit 632 (Coroner) Dues* Supervising Coroner Investigator I [$97.23] Supervising Coroner Investigator II [$105.29] Unit 995 (Captain/Commander) Dues* Captain [$119.33] Commander [$119.33] Includes $5 political action deduction*Check below if you decline to include the $5 political action deduction. Accept Decline Star & Shield Charitable Foundation*Voluntary charitable monthly deduction $2 $5 $10 $20 Other Decline Other Amount* Total $0.00 I hereby authorize the auditor of the County of Los Angeles or his agents to deduct monthly from salary earned by me in any department of the County of Los Angeles the amount shown hereon and to pay same to. If all or any portion of the deduction authorization includes insurance premiums and/or employee organization dues, I also authorize the auditor to adjust from time to time the amount of the deduction as may be required to comply with adjustments in County subsidy amounts in premiums under existing contracts with said insurance plans or to comply with dues schedules determined by said employee organizations governing body in accordance with such organizations constitution, charter, by-laws or other applicable legal requirements. This authorization cancels and replaces any previously signed by me by written notice. I expressly understand and agree that auditor, his agents or the County acting under this authorization shall not be liable in any manner for the failure or delay in making the deduction or payments here authorized. I understand that I can resign from membership in PPOA at any time; but whether or not I resign my membership, I agree to be contractually obligated to continue my payroll deduction, as authorized herein, as long as I continue to be employed by the County in a bargaining unit represented by PPOA, unless I send PPOA written notice to terminate my payroll deduction. I understand that the written notice to PPOA to terminate my payroll deduction is only valid if received by PPOA during a 30-day open window period each year that commences on the anniversary date of my becoming a member.Signature* Signature Date* MM slash DD slash YYYY CAPTCHAPlease enter the following characters in the field below.