Fairfax County Police Association Application

FAIRFAX COUNTY POLICE ASSOCIATION

Membership Application
Member Name (print):

First NameMiddle InitialLast Name
Social Security Number:
#########
Date of Birth (mo/day/yr):

MonthDayYear
Date
MaleFemale
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SingleMarriedWidowedDivorced
E-mail Address:
example@example.com
Phone Number (include area code):
Format: (000) 000-0000.
NewRe-instatementSpouse
SwornNon-Sworn
Current Rank:
Current Station Assignment or Unit & Location:
Life insurance benefits for which this Association becomes liable by the acceptance of this application and continued good standing of the member as provided for in the By-laws will be paid to the named beneficiary or the contingent beneficiary, whichever survives the applicant. Should the applicant survive both, his or her spouse becomes the beneficiary unless the applicant names another by written request.

I wish to become a member of the Fairfax County Police Association and agree to pay the required monthly dues. I authorize the Fairfax County Government to deduct from my earnings such amounts of dues as may now or hereafter be payable by me to the Fairfax County Police Association.

I hereby pledge to abide by the By-laws of the Association and fulfill all obligations inherent with my membership.
Signed:
Date:

MonthDayYear
Date
EMPLOYEE PAYROLL DEDUCTION AUTHORIZATION
Name:
First Name Middle Name Last Name
SSN:
#########
Deduction: $18.25/pay period
I hereby authorize my employer, the Fairfax County Government to deduct from my earnings such amounts of dues as may now or hereafter be payable by me to the Fairfax County Police Association. This agreement shall remain in effect until such time as it is amended or rescinded by me in writing. I understand that the FCPA is NOT the exclusive bargaining agent for my bargaining unit and therefore is not eligible to represent me if an exclusive bargaining agent has been elected and certified for my bargaining unit.
Signature:
Date:

MonthDayYear
Date
Should be Empty:

FAIRFAX COUNTY POLICE ASSOCIATION

EMPLOYEE PAYROLL DEDUCTION AUTHORIZATION