Pulaski County FOP 27 Membership Petition

First Name:

Middle Initial:

Last Name:

Address:

City, State: , AKALARASAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVIVTWAWIWVWY

Zip Code:

Phone (Home):

Phone (Cell):

Personal E-mail: (County Email Cannot Be Used)

Enforcement or Detention: Choose One...EnforcementDetention

Birthdate:

Social Security Number:

Beneficiary Name and Relationship:

Beneficiary Phone:

Beneficiary Address:

I,  hereby authorize the Pulaski County Payroll Division to deduct the following amount from my payroll check for the Fraternal Order of Police, Lodge #27. Choose One...$10.00 Membership Level 1 (Membership$12.00 Membership Level 2 (Membership with Civil and Criminal Defense Plan)$20.00 Membership Level 3 (Membership with Civil, Criminal and Administrative Defense Plan)$5.00 Auxiliary Membership (Civilian, Reserve)

PETITIONER’S SIGNATURE: Signature: Use your mouse, finger, or touch device to write your signature. Clear

Date: