Suffolk Police Columbia Association
Membership Application

PO BOX 160, YAPHANK, NY 11980

www.suffolkpolicecolumbia.org

MEMBER OF THE NATIONAL COUNCIL OF COLUMBIA ASSOCIATIONS IN CIVIL SERVICE INC.

 

Name:______________________________________________________________________________
Address:____________________________________________________________________________
City / Hamlet:________________________________________________________________________
State:______________________________________________________________________________
Zip:_______________________________________________________________________________
Phone:_____________________________________________________________________________
email:______________________________________________________________________________
Employer:__________________________________________________________________________
Date Employed:______________________________________________________________________
Rank:_____________________________________________________________________________
SS# ______________________________________________________________________________
Proprosed By:_______________________________________________________________________
Signature: __________________________________________________________________________
Pay roll deduction is automatic:
Date of Acceptance:__________________________________________________________________