Retired Police Membership Application

APPLICANT'S INFORMATION

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FIRST NAME *

MIDDLE NAME

LAST NAME *

DATE OF BIRTH *

ADDRESS *

CITY *

COUNTY *

STATE *

ZIP + FOUR *

BEST PHONE NUMBER *

ALTERNATE PHONE NUMBER

EMAIL ADDRESS *

ALTERNATE CONTACT NAME OTHER THAN BENEFICIARY *

RELATIONSHIP TO APPLICANT

BEST PHONE NUMBER *

ALTERNATE PHONE NUMBER

ALTERNATE'S ADDRESS *

CITY *

STATE *

ZIP *

RETIREMENT INFORMATION

DEPARTMENT/AGENCY RETIRED FROM *

PHONE NUMBER *

ADDRESS *

CITY *

STATE *

ZIP *

Pension Type

SERVICE DATES FROM *

SERVICE DATES TO *

RETIREMENT SYSTEM *

REASON FOR RETIREMENT *

LAST 4 DIGITS OF SOCIAL SECURITY # *0 / 4

Affadavit

REQUIREMENTS FOR ADMISSION TO THE
RETIRED POLICE ASSOCIATION OF THE STATE OF NEW YORK, INC.

ART. IV DEFINITIONS

POLICE OFFICER: For the purpose of this Constitution and By-Laws, the term “Police
Officer” shall mean a Police Officer as defined in Section 1.20, Subd. 34 of the Criminal
Procedure of Law of the State of New York.

RETIRED POLICE OFFICER: Not withstanding any provision of any law, rule or regulation
of the State of New York, or any organization or association legally constituted therein, the
definition of “Retired Police Officer” for the purpose of membership in this Association shall
include, and shall only include persons who were Police Officers as defined herein and who
have been employed and honorably retired from a law enforcement agency of the State, County,
Town, City, Village, Public Authority, or Police District within the confines of New York State.

ART. V MEMBERSHIP:

1 A(1) ACTIVE MEMBERS
Any person, male or female, who served as a Police Officer as the term “Police Officer” is
defined in Section 1.20, Subd. 34 of the Criminal Procedure Law of the State of New York, and
who has retired after having served honorably as a Police Officer in any law enforcement agency
of the State, County, Town, City, Village, Public Authority, or Police District within the confines
of New York State, or
while serving honorably as a Police Officer of a law enforcement agency as described herein, is
discharged under honorable conditions as disabled or unfit for duty because of an on or off-duty
injury or illness,
is eligible for membership in this Association.

HAVING READ THE REQUIREMENTS FOR MEMBERSHIP TO THE RETIRED POLICE
ASSOCIATION OF THE STATE OF NEW YORK, INC., AND COMPLETED THE APPLICATION FOR
MEMBERSHIP, I AFFIRM THAT I QUALIFY FOR MEMBERSHIPASA RETIRED POLICE OFFICER
AND THAT I FULFILL THE REQUIREMENTS FOR ACTIVE MEMBERSHIP AS DESCRIBED
HEREIN, AND THAT MY APPLICATION FOR MEMBERSHIP IS TRUTHFUL, ACCURATE AND
COMPLETE. FURTHER, I UNDERSTAND THAT ANY FALSE INFORMATION OR STATEMENT
MADE ON THIS APPLICATION AND/OR FAILURE TO MEET THE REQUIREMENTS FOR
MEMBERSHIP MAY BE CAUSE FOR REJECTION OR IMMEDIATE TERMINATION FROM THE
ASSOCIATION.

Signature *

Start drawing your signature here

*By signing this application, you verify that all the information provided is correct and that you have met the qualifications for membership in the RPA.

Important Information:

Membership Dues: $45 per year by check, or $47.25 if paying by Credit Card or PayPal.

RENEWS AUTOMATICALLY SEPTEMBER 1ST OF EACH YEAR.

LATE FEE OF $10 WILL BE ASSESSED IF PAYMENT IS NOT RECEIVED BY JAN 31ST, OTHERWISE MEMBERSHIP WILL BE SUSPENDED.

Your Membership Application will not be accepted if you do not purchase an annual subscription. You will be redirected to another page to complete your membership application subscription.

If your application is not accepted, you will be refunded.

FOR OFFICE USE ONLY

CHECK NUMBER: _____________________

CHECK AMOUNT ($): __________________

DATE RECEIVED: _____________________

DATE APPROVED: ____________________

RECORD NUMBER: ___________________

Financial Secretary Signature:

_____________________________

ENTERED IN COMPUTER No / Yes Date:___________

WAS BENEFIT CARD RECEIVED? No / Yes Date:___________

Beneficiary InformationAdd your beneficiary information below

Beneficiary or Donate to RPA Scholarship Fund

Please fill out (A) beneficiary's information , or (B) fill the circle for donating death benefit to scholarship program. Only one choice can be made.

Selected Beneficiary Choice *(A) I, chose a beneficiary and have provided the beneficiary's information below(B) I, choose to donate my death benefit to the RPA Scholarship Fund in place of an individual beneficiary.IF CIRCLE (A) IS SELECTED, PLEASE ENSURE BENEFICIARY INFORMATION IS ENTERED IN AT THE BOTTOM OF THIS FORM BEFORE SUBMITTING.

Retired Police Association of the State of New York, Inc.

Members Benefit Information Card

Member Name:

YOUR FIRST NAME (MEMBER)

YOUR LAST NAME (MEMBER)

(A) BENEFICIARY NAME

BEST PHONE NUMBER

ALTERNATE PHONE NUMBER

RELATIONSHIP

BENEFICIARY ADDRESS

CITY

STATE

ZIP

ALTERNATE BENEFICIARY NAME

BEST PHONE NUMBER

ALTERNATE BENEFICIARY PHONE NUMBER

RELATIONSHIP

ALTERNATE BENEFICIARY ADDRESS

CITY

STATE

ZIP

Please do not fill in this field.

Retired Police Membership Application

APPLICANT'S INFORMATION

RETIREMENT INFORMATION

REQUIREMENTS FOR ADMISSION TO THE
RETIRED POLICE ASSOCIATION OF THE STATE OF NEW YORK, INC.

Important Information:

Your Membership Application will not be accepted if you do not purchase an annual subscription. You will be redirected to another page to complete your membership application subscription.

If your application is not accepted, you will be refunded.

Beneficiary or Donate to RPA Scholarship Fund

Retired Police Association of the State of New York, Inc.

Members Benefit Information Card

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Retired Police Membership Application

APPLICANT'S INFORMATION

RETIREMENT INFORMATION

REQUIREMENTS FOR ADMISSION TO THERETIRED POLICE ASSOCIATION OF THE STATE OF NEW YORK, INC.

Important Information:

Your Membership Application will not be accepted if you do not purchase an annual subscription. You will be redirected to another page to complete your membership application subscription.

If your application is not accepted, you will be refunded.

Beneficiary or Donate to RPA Scholarship Fund

Retired Police Association of the State of New York, Inc.

Members Benefit Information Card

About

Contact Us

Welcome to RPAS - Retired Police Association of New York

REQUIREMENTS FOR ADMISSION TO THE
RETIRED POLICE ASSOCIATION OF THE STATE OF NEW YORK, INC.