Membership – Los Angeles Fire and Police Veterans Association

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Agency You Work For *

Military Branch *

Are you in a reserve unit that deploys? *

Employee ID Number Or Badge Number *

Are you receiving VA Disability Compensation?

$2.50 Bi-Weekly Paycheck Deduction

I hereby authorize the deduction from my salary and the payment to LAFPVA. Such sum may be properly specified in the By-Laws of the Association.

Signature *

Clear Signature

Date *