INTRA-DEPARTMENTAL MEMBERSHIP AUTHORIZATION

Member Information:

Name:  

Social Security Number: Serial Number (if applicable):  

Street Address: App/Unit/Space #  

City: State: Zip:  

Work Phone:   Cell Phone:  

E-mail Address:  

(Email address is used for LAPRAAC communication only, i.e. admin correspondence, quarterly newsletter, and upcoming specials.)

 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.  Please enter your full legal name, your e-mail address and then e-sign at the bottom of the form.

 

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Signature Certificate
Document name: Other Agency LAPRAAC Membership Form
lock iconUnique Document ID: f6d4ef2cc1ecb976779afc4c60f6b75902e7d7d2
Timestamp Audit
August 20, 2021 7:44 am PSTOther Agency LAPRAAC Membership Form Uploaded by Ruben Crane - rcrane@lapraac.com IP 174.127.55.122