Quarterly Billing Membership Application
 
  -   -  
 Social Security Number
 
First Name
Middle Initial		  
Last Name
 
Mailing Address
 
City		  
County

State		  
Zip
 

Home Phone 

  
Work Phone		  
Cell Phone
 
Date of Birth		  
E-mail
Rank 
 
 Name of Public Employer		  
State of Employer
Employment Start Date

 

PRIMARY BENEFICIARY

 *Claims are paid to the listed beneficiary regardless if the status of the relationship changes.
  -   -  
 Social Security Number		  
Date of Birth
 
 Current Relationship
 
First Name
Middle Initial		  
Last Name
 
Mailing Address
 
City		  
County
 
State		  
Zip
 
Home Phone

 
Other Phone

 

SECONDARY BENEFICIARY

         ** Secondary beneficiary is eligible for benefits if primary beneficiary is unavailable.
  -   -  
 Social Security Number		  
Date of Birth
 
 Current Relationship
 
First Name
Middle Initial		  
Last Name
 
Mailing Address
 
City		  
County
 
State		  
Zip
 
Home Phone		  
Other Phone

*** If no beneficiary is named or if beneficiary is unavailable, benefits will be paid to the member's estate.

 

Payment:  

  I allow Southern States PBA to charge $10 to my credit card for this one time initiation fee.

Dues will be billed to me quarterly.

** Membership will not begin until the credit card is approved.
Payable to: Southern States PBA   Amount of Payment  $ 10.00
 

Name on Credit Card:

Credit Card Type: 

Credit Card Number:

If you are using an American Express Card, please enter a 0 at the beginning of the card number!

  

Expiration Date: 

TERMS AND CONDITIONS:  By signing your name in the box below and submitting your application, you agree to becoming a member of the Southern States Police Benevolent Association and promise to abide by the constitution and by-laws of this association.

 
Date

  
Signature Required (Type name in box above)

Coverage will begin on the day provided to you by Southern States PBA, which will be done by email within the next few days.  This date may not correspond with the date that you submitted your application. 

 

Thanks for your interest in PBA! Our dues include a $.50 per month voluntary contribution to our PAC fund.  For inquiries or to cancel this important contribution, call 800-233-3506.

 

To insure your beneficiary information is file.

Please read and fill this form to make sure the fields are correct, print two copies and mail one to:
Southern States PBA
2155 Highway 42 S
McDonough, GA  30252

THIS BENEFIT IS AT NO ADDITIONAL COST TO YOU!