For use by Sworn and Civilian Employees of CSPD only.
Please print; fill out; sign; initial; and fax to 719-634-0755 or email to Sherryl@csppa.org
In order to serve the needs of CSPPA members and their families, the following information is requested. Please fill out and return to the CSPPA office. Information will be kept personal and confidential.
NAME
Last, First, Middle: __________________________________________________________
ADDRESS: ________________________________________________________________
CITY, STATE, ZIP: ___________________________________________________________
________________________________________________________________________
HOME #: _______________________________________
WORK #: _______________________________________
CELL #: ________________________________________
DATE OF BIRTH: _________________________________
PERSONAL EMAIL: _______________________________
(The CSPPA does not use CSPD email to conduct business)
JOB TITLE: _________________________
IBM#: ______________ HIRE DATE: _________________________________
SOCIAL SECURITY NUMBER: ________________________________________
SPOUSE NAME: ___________________________________ DOB: ____________________
CHILDREN:
M/F DOB _____________________________________________________________
M/F DOB _____________________________________________________________
M/F DOB _____________________________________________________________
M/F DOB _____________________________________________________________
BENEFICIARY NAME and RELATIONSHIP: _____________________________________________________
BENEFICIARY ADDRESS: __________________________________________________________________
In the event of death, the beneficiary information is most important to help expedite the disbursement of benefits. This also should be updated should your situation change.
YOUR SIGNATURE: __________________________________________________________
DATE: ___________________________________
I authorize the Colorado Springs Police Protective Association to deduct my
membership dues from my paycheck. INITIAL: ______________
Going Fast! Get Your Lawn Signs Now!
Colorado Springs…let’s show our CSPD officers that our community supports them! Order your lawn sign now… they are $10 each, with 100 percent of sales benefiting the Colorado Springs Police Protective Association Fallen Officer Relief Fund. The Fund provides immediate financial assistance to Pikes Peak region law enforcement officers who have been catastrophically injured or killed in the line of duty. For more information, call 719-634-0058. Thank you!
