RFPA APPLICATION

RFPA MEMBERSHIP APPLICATION
Name*

First NameMiddle InitialLast Name
Nickname:
Spouse:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home Number

Area CodePhone Number
Cellular Number

Area CodePhone Number
Rank When Retired:*
Agency:*

PoliceFireLifeguard
Status:*

Retired - No Longer WorkingDROP - Still Working
Retirement Date (same as DROP start):*
Please enter the date when you will start receiving your SDCERS pension check:
Starting date SDCERS pension checks:
You authorize your dues to be paid by monthly payroll deduction:
FULL Social Security number for dues:*
Should be Empty: