Application for Reserve Membership Name* First Middle Last GenderMaleFemaleDepartment*Job Title/Rank*Date Entered County Service* Date Format: 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* Date Format: MM slash DD slash YYYY Personal Email (non-LASD)* Dues*Reserve members are to pay for the remaining months ($25 per month) of the calendar year upon submission of this application. Example: Join PPOA in July, pay $150 (6 mos. @ 25 per month). Checks payable to PPOA. Please call Clare at PPOA with any questions: (800) 747-PPOA. Price: $100.00 Star & Shield Charitable Foundation*Voluntary charitable monthly deduction$2$5$10$20OtherDeclineOther Amount* Total $0.00 I hereby apply for membership in the Los Angeles County Professional Peace Officers Association. I authorize annual payments equivalent to monthly dues total 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.)Signature*Signature Date* Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.