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Pulaski County FOP 27 Membership Petition

First Name:
 
Middle Initial:
 
Last Name:
 
Address:
City, State:
,
Zip Code:
 
Phone (Home):
Phone (Cell):
E-mail:
Enforcement or Detention:
Birthdate:
Social Security Number:
Beneficiary Name and Relationship:
Beneficiary Phone:
Beneficiary Address:
I,  hereby authorize the Pulaski County Payroll Division to deduct the following amount from my payroll check for the Fraternal Order of Police, Lodge #27.
PETITIONER’S SIGNATURE:
Signature:

Use your mouse, finger, or touch device to write your signature.
Date:

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Pulaski County Fraternal Order of Police Lodge27
8505 Doyle Springs Road
Little Rock, AR 72203
 


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