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 New York State Police Chief's
Benevolent Association, Inc.
1887 East Main Street
Peekskill, New York 10566
Phone & Fax number (914) 788-7089

Name:
Title or Status:
Home Address:
Home Phone:
 Home Fax:
Work Address:
 Do you want your mail to go to your: Home Office
Agency or Business Name:

Business Phone:
 Business Fax:

Applications for Actice or Retired Members must have the bottom part of this form completed.
All application forms must be signed and have the appropriate membership fee attached
Employing authority:
 State County  City  Town  Village  Other
Social Security Number:

Date of Birth:

NOTE: Your social security number and date of birth are for the FOP Lodge and FOP Legal Plan. They will not be given to anyone else
The NYSPCBA, Inc. reserves the right NOT to accept membership for anyone currently under any employment action
I certify that the answers to the questions on this application are true and factual, I understand that my association with or membership in the NYSPCBA, Inc. may be terminated if any of the information on this application is not true or is incomplete.

Signature:
Date:
Membership Fees: {Check off the amount of your dues}
Active Member CBA Annual Membership $ 50.00
FOP CBA Lodge 154 $ 20.00
FOP Legal Defense Plan Yearly Premium $137.00
Only if you join in December for the next full year; for any other month,
Please call (914) 788-7089 for price quote by the month
Retired Member CBA
FOP CBA Lodge 154 $ 20.00
CBA Annual Membership $ 10.00
Associate Member CBA
Corporate - Annual Membership $100.00
Individual - Annual Membership $ 50.00
Print Form Then Fax or Mail To The CBA