Application for Reserve Membership

Name*
First Middle Last
Gender
- Male
- Female
Department*
Job Title/Rank*
Date Entered County Service*
County Employee Number*
Last 4 digits of SSN*
Place of Assignment*
Home Address*
Street Address Address Line 2 City State ZIP Code
Work Phone*
Cell Phone*
Date of Birth*
Personal Email (non-LASD)*
Deduction Agency*
Deduction Code*
Monthly Membership Dues Deduction*
Reserve members are to pay for the remaining months ($25 per month) of the calendar year upon receipt of this application. Example: Join PPOA in July, pay $150 (6 mos. @ 25 per month).
Price: $25.00
Star & Shield Charitable Foundation*
Voluntary charitable monthly deduction
- $2
- $5
- $10
- $20
- Other
- Decline
Other 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*
Phone
This field is for validation purposes and should be left unchanged.

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