Monthly Credit Card Draft 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 Agency		  
State of Employer
Employment Start Date

Payment:  

  I allow Southern States PBA to draft my credit card $23.50.  Dues will be drafted from my credit card on the 22nd of each month until the PBA is notified otherwise by me.

** Membership will not begin until the credit card is approved.
Payable to: Southern States PBA   Amount of Payment  $ 23.50
 

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 typing 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.