Last Name:
First Name:
MI:
Address:
City:
State:
Zip:
Phone:
Agency Retired From:
State:
Date of Birth:
Date of Retirement:
Rank at Retirement:
Email Address:
First Name of Spouse:
Dues are $20.00 per calendar year or any portion thereof (Jan 1 – Dec 31)
Life Membership is available for a one-time payment of $200.00
Include proof of retirement when you submit your application.
Print this form and mail it along with your check made payable to RDPOA, to:
Retired & Disabled Police of America
1317 N. San Fernando Blvd., #319
Burbank, CA 91504
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