MEMBERSHIP APPLICATION
SANTA CLARA COUNTY PEACE OFFICERS ASSOCIATION
Mail to P.O. Box 24948, San Jose, CA 95154
Phone: 408-264-1224 * www.sccpoa.org
MEMBERSHIP APPLICATIONSANTA CLARA COUNTY PEACE OFFICERS ASSOCIATIONMail to P.O. Box 24948, San Jose, CA 95154Phone: 408-264-1224 * www.sccpoa.org |
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| Name | ||||||
| Address | City | California | Zip | Agency | ||
| Agency ID | Agency Phone | Rank/Title | Associate Regular Reserve | |||
| Spouse | Phone | |||||
| Sex: | Male | Female | DOB | |||
| Age | Dependents | |||||
| Email Address | ||||||
| YEARLY MEMBERSHIP | Effective January 1 - December 31 | |||||
| Membership: | Active $75 | Retired $50 | ||||
| *Full Payment Required | ||||||
| Optional AD&D INSURANCE | Effective May 1 - April 30 | |||||
| AD&D Insurance Coverage Requested: $15/year | ||||||
| *Full Payment Required | Beneficiary | |||||
| Relationship | Age | |||||
| Address | ||||||
| City | State Zip | |||||
| Total Amount Enclosed ** | ||||||
| Signed | ||||||
| Date | ||||||
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