Application for Service Membership

Name*
First Middle Last
Gender
- Male
- Female
Job 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 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
- $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*
Date Format: MM slash DD slash YYYY

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