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_____/_____/_____ 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: ($300 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 $30 Make checks payable to NYCRTPOA and mail to:
NYC Ret. TPO Assoc.
PO Box 345
East Rockaway, NY 11518-0345
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