Application for Service 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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)* Deduction Agency* Deduction Code* Monthly Membership Dues Deduction* Price: 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 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* MM slash DD slash YYYY CAPTCHAPlease enter the following characters in the field below.