Last Name_________________________ First____________________________________

Address________________________________________________ Apt. # _____________

City_______________________________________ State______ Zip(+4)_______-_______

Telephone # (___)_______________________

Rank _________Date Appointed_____/_____/_____ Date Retired______/______/_______

Email____________________________________ D.O.B._____/_____/______

Tax ID # (if known)______________________

Lifetime Membership for those 75 years or older.  If eligible, please check
here ____ and make sure you have filled out your DOB above. Dues must have been
paid for the 3 years prior to turning 75.

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

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: _______________________________

Dues are $25.00

NYC Ret. TPO Assoc.
PO Box 345
East Rockaway, NY 11518-0345

Make checks payable to NYCRTPOA