LANDMARK CHIROPRACTIC SIGNUP FORM
PAYROLL DEDUCTION AUTHORIZATION (RETIRED SEBA MEMBERS)
I authorize the Sheriff’s Employees’ Benefit Association (SEBA) to deduct the amount indicated below on a monthly basis.
Member Name
*
First Name
Last Name
Personal Email
*
example@example.com
Employee ID #
*
Today's Date
*
-
Month
-
Day
Year
Date
Select your option
Choose only one
Select your option
*
Retired SEBA Member Only - $10.00 per month
Retired 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 Name
Last Name
Spouse's Date of Birth
-
Month
-
Day
Year
Date
SEBA USE ONLY
Processed By:
Date Processed:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: