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MEMBERSHIP APPLICATION

Dues for 2022 are Due, dues are $30.00 per year
and
 "Life TIME"  Members PAY $10.00  Assessment

​Mail Dues to: 

NEW  ADDRESS 

​10-13 Club of Northeast Fl

PO Box 291862

  Port Orange, FL  32129 

Click The Link Below To Download The Application

  PLEASE        PRINT       ALL        REQUESTED         INFORMATION
​LAST NAME ____________________     FIRST _____________________   MI______
ADDRESS____________________________         CITY__________________ STATE_____
ZIP CODE_________    HOME PHONE (____  )________________       CELL (___)_______________ SPOUSE'S NAME _________________________    EMAIL  ADDRESS ________________________
BENEFICIARY'S   NAME  FOR  SURVIVOR’S  FUND  _____________________________                 
BIRTH DATE ____/____/______        ANNUAL DUES ARE $30.00          CHECK #_____________
APPOINTMENT DATE____/____/_______                      RETIREMENT DATE ___/___/______ 
                                                                                                                                          ATTACH Photo Copy  
                                                                                                                                                  of  DEPT  ID
PENSION #(REQ'D)__________________   LAST COMMAND_____________  LAST RANK________
LIST ALL PREVIOUS COMMANDS     ___________________________________________________
                                                           ASSOCIATE  MEMBERS
LAW ENFORCEMENT AGENCY________________________TELEPHONE (      ) ________________
RANK_______            RETIRED (    ) ACTIVE (    )               MILITARY  ACTIVE   (    )     RETIRED (    )
                        

Signature______________________                                     Date ____ /_____ /_______

MAKE CHECK PAYABLE TO:  NE, FL 10-13  SEND to  PO Box 291862,  Port Orange FL  32129
ALONG  WITH THIS APPLICATION 
 

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