Prime Fitness Signup Form (Retired Members)

PRIME FITNESS SIGNUP FORM

PAYROLL DEDUCTION AUTHORIZATION (ASSOCIATE / RESERVE / EXEMPT MEMBERS)
I authorize the Sheriff’s Employees’ Benefit Association (SEBA) to deduct the amount indicated below on a monthly basis.
Member Name*

First NameLast Name
Personal Email*
example@example.com
Employee ID #*
Today's Date*

MonthDayYear
Date
Select your option

Choose only one
Select your option*

Retired SEBA Member Only - $10.00 per monthRetired SEBA Member & Spouse (see below) - $25.00 per month
Spouse is your legally married partner or registered domestic partner as recognized by the state of California.
Spouse's Name

First NameLast Name
Spouse's Date of Birth

MonthDayYear
Date
Prime Fitness membership activation can take up to two weeks. Visit www.primemember.com and click on “Sign Up” often to check status.

Once activated, you may download and print your Prime Fitness membership card(s). Take that card to the participating fitness facility of your choice. For Prime Fitness customer service call 1-877-238-6240, or SEBA at 909-885-6074.
SEBA USE ONLY
Processed By:
Date Processed:*

MonthDayYear
Date
Should be Empty:

PRIME FITNESS SIGNUP FORM