Mississippi 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:
 

Please complete this form,  print it, sign it, and then mail to:
Southern States PBA
2155 Highway 42 South
McDonough, GA  30252

phone: 800-233-3506