Deputies Law Enforcement Association Application

Deputies Law Enforcement Association
Committed to Representing the Professional Deputy Sheriff
1102 W Adams Phoenix, AZ 85007
www.azdlea.com
Date: *

Month Day Year
Date
Membership Application
Name: *
Serial #: *
Mailing Address: *
City: *
Zip Code: *
Cell Phone: *
D.O.B. *
Home E mail: *
example@example.com
Work Location/Division *
Rank: *
Any pending investigations? *

No Yes
If yes describe:
Active Member (Deputy) - $36.00 per month
Bank Account # *
Routing # *
Bank Name # *
Savings or Checking? *
I, the applicant and undersigned, authorize the Deputies Law Enforcement Association to electronically draft monthly dues in the amount approved by the Board of Directors of the Association for an Active Member of the DLEA. I understand that while I am a current dues paying Active Member of the Association, I am entitled to any benefits adopted by the Board of Directors and in compliance with the Fair Representation and Legal Policy of the Association. I further understand the amount for monthly dues may be changed at the direction of the Board of Directors of the Association, but not without written notice either electronically or by other means prior to the dues being changed. It is my responsibility to maintain current account information with the Association, or I understand that my membership could be suspended along with any benefits I would be entitled to, and be subject to fees incurred by the Association as a result of delinquent information.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Deputies Law Enforcement Association

Membership Application