Application for Service Membership Name* First Middle Last GenderMaleFemaleJob Title/Rank*Department*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)* Deduction Agency*Deduction Code*Monthly Membership Dues Deduction* Price: $10.00 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 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.)Signature*Signature Date* Date Format: MM slash DD slash YYYY
Los Angeles County Professional Peace Officers AssociationLos Angeles County Professional Peace Officers Association