INTRA-DEPARTMENTAL MEMBERSHIP AUTHORIZATION
Social Security Number: Serial Number (if applicable):
Street Address: App/Unit/Space #
City: State: Zip:
Work Phone: Cell Phone:
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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Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Other Agency LAPRAAC Membership Form
Agree & Sign