MEMBERSHIP APPLICATION

UPDATED
January 20, 2017



PLEASE PRINT OUT THIS FORM, FILL IT OUT AND SEND WITH A CHECK
TO THE ADDRESS BELOW

 

Last Name_________________________ First______________________________

Address___________________________________________ Apt. # _____________

City_________________________________  State______ Zip(+4)_______-_______

Telephone # (___)_______________________

Rank _________Date Appointed to NYCTPD _____/_____/_____ (for regular membership)

Date Retired ______/______/______

For Associate Membership: PAID member sponsoring :________________________

Email_______________________________________________________________

D.O.B._____/_____/______

Tax ID # (if known)______________________

Lifetime Membership for those who are 75 years or older
Dues must have been paid for the 3 years prior to turning 75.

If eligible, please check here ____ and make sure you have filled out your DOB above.



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


Beneficiary: $300 Death benefit payable to members who are paid up for previous 3 years
                             (Note: Does not apply to Associate or Honorary Membership)

Name____________________________________________________________

Relationship to
Member__________________________________________________________

Address__________________________________________________________

City__________________________  State_______  Zip (+4)________-______

Telephone: _______________________________


Dues are $30            Make checks payable to NYCRTPOA and mail to:

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