RETIRED & DISABLED POLICE OF AMERICA

Name:
Address:
City:
State	Zip Code:
Telephone Number:
IMPORTANT NOTICE: All pocket badge orders must be accompanied by documented proof of retirement from a recognized law enforcement agency or military police unit. Please indicate the information as you want it to appear on each nameplate. The top nameplate contains the name and rank of the member and the bottom nameplate contains the agency from which the member is retired. Each nameplate can accommodate two lines and each line can accommodate up to 20 characters including spaces and punctuation. Top Nameplate Line 1: Top Nameplate Line 2: Bottom Namepalte Line 1: Bottom Nameplate Line 2: 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 $60.00, to: Retired & Disabled Police of America 1317 N. San Fernando Blvd., #319 Burbank, CA 91504-4272