ACTIVE MEMBER DEDUCTION AUTHORIZATION
Fund Code 4301
Social Security Number: Serial Number (if applicable):
Street Address: App/Unit/Space #
City: State: Zip:
Work Phone: Cell Phone:
I hereby authorize the deduction, as indicated below by my initials, from my salary, to be paid to the Los Angeles Police Relief Association, Inc. (LAPRA), to cover my membership dues in the Los Angeles Police Revolver and Athletic Club, Inc (LAPRAAC).I also authorize LAPRAAC to instruct LAPRA on my behalf to increase or decrease such payroll deductions in an amount equal to any increase or decrease in the applicable bi-weekly dues.This authorization shall be effective as indicated below. I understand the minimum length of membership with LAPRAAC is for one year. Once the minimum length of one year has been fulfilled, the membership with LAPRAAC can be cancelled by me or LAPRAAC. A photocopy, facsimile or electronic copy of this authorization shall be deemed to be as valid as the original signed document. Mark your initials in the table below, enter your full legal name, your e-mail address and then e-sign at the bottom of the form.
For LAPD Officers will find their deduction on their pay check:
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: LAPD Membership Form
Agree & Sign