LOS ANGELES COUNTY HISPANIC MANAGERS MEMBERSHIP APPLICATION

LOS ANGELES COUNTY HISPANIC MANAGERS MEMBERSHIP APPLICATION
(Monthly Dues $4.00) Via Payroll Deduction
Full Name*
Employee No*
Payroll Title*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Department*
Department Number
Work Email*
example@example.com
Personal Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Membership

I hereby authorize the Professional Peace Officers Association (or LACHMA agent) to deduct monthly from salary earned by me in any County/Court department/agency from which I am employed the amount below:

LACHMA Membership dues are $4.00 a month and are collected via payroll deduction through the Professional Peace Officers Association (PPOA)

This authorization cancels/replaces any previous authorizations approved by me with this department/agency and shall remain in effect until I have provided written notice and mailed such notice to LACHMA's address. I understand and agree that removal of this deduction may require up to ninety (90) days from receipt of written notice due to County Auditor and PPOA accounting systems.
Signature of Employee*

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Date*

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