MEMBERSHIP FORM for The NYC Retired Transit Police Officers Association


Last Name___________________________First________________________________

Address_______________________________________________Apt #______________

City_______________________________State____________Zip (+4) ____________


Telephone # (_____)__________________ 

Rank _________Date Appointed_______________Date Retired__________________

Email______________________________________________ DOB__________________

Type of Retirement: (   ) Service (   ) Ordinary Disability 
                    (   ) Accidental Disability  (   )  Vested

Lifetime member: Check here _____ and indicate your DOB above
                 Note: only available for members 75 yrs. and older 
                 and paid up for 3 years prior to age 75.

Beneficiary: ($250 Death benefit payable to members who are paid up for previous 3 years)

Name____________________________________________________________________

Relationship to
Member__________________________________________________________________

Address_________________________________________________________________

City___________________________State____________Zip (+4)______-_________

Telephone: (_____)_______________________


NYC Ret. TPO Assoc.                   Dues are $25.00 
PO Box 345                            Make checks payable to 
East Rockaway, NY 11518-0345	        NYC RTPO Assoc.