Membership Application

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: ______________