Application for Membership

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 $15.00 per calendar year or any portion thereof (Jan 1 – Dec 31)
Life Membership is available for a one-time payment of $150.00

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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