Arkansas Payroll Deduction 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

Employee Number

*If your agency is not on this list, you are not eligible for payroll deduction at this time.  Please use a different application for membership.

 
 

Employees' Authorization

 

I hereby authorize my employer to deduct from my salary the membership dues as established by the Southern States Police Benevolent Association, Inc.  I understand that this amount will be deducted until 1) revoked by me at any time upon 30 days written notice to the employer, or 2) termination of my employment.  I understand that dues are calculated by SSPBA and are subject to change periodically, and I therefore authorize the agency to adjust my payroll deduction as necessary.  The deduction made pursuant to this authorization shall be transmitted to:

 
Member's Signature:  Date
 

First, please print this form out!  Second, click the next button.

MAKE SURE YOU HAVE PRINTED THIS PAGE OUT AND SIGNED IT BEFORE MOVING ON TO THE NEXT PAGE!
(Your application can not be processed without this page being printed out, signed and mailed in)

NEXT