RETIRED & DISABLED POLICE OF AMERICA

RETIREMENT BADGE ORDER FORM
Name:
Address:
City:
State Zip Code:
Telephone Number:
IMPORTANT NOTICE: All badge orders must be accompanied by documented proof of retirement from a recognized law enforcement agency or military police unit. You must be a member of the Retired & Disabled Police of America to order this Badge.

Indicate the information as you want it to appear on your three-line nameplate.
Each Line can accommodate up to 20 characters including punctuation and spaces.

Line 1:

Line 2:

Line 3:

State of Agency:

Print this form and mail it along with proof of retirement and your check or money order,
payable to RDPOA, in the amount of $85.00, to:

Retired & Disabled Police of America
1317 N. San Fernando Blvd., #319
Burbank, CA 91504-4272

You must be a member of the Retired & Disabled Police of America to order this Badge.