Join The PBA

Florida Police Benevolent Association Membership Application

Social Security #

Employer # or People's First ID #

First Name (required)

Last Name (required)

Address

City (required)

State (required)

Zip Code (required)

Employing Agency (required)

Institution/Troop/Region/Division, if applicable

Home/Cell Phone Number (required)

Date of Birth (required)

Date of Employment (required)

Rank (required)

Personal (Non-work) E-Mail Address (required)

Recruitment Information - If Applicable

Each member who recruits another member may receive $25.00 from the Florida PBA!

Recruited By

Recruiter - Last 4 of SSN

Billing

Select Billing Option

I direct my employing agency to deduct from my wages the appropriate FLPBA dues in accordance with collective bargaining or other agreement between PBA and the agency, if available. This authority will remain in effect until such time as I provide 30 days written notice to FLPBA and the agency to terminate said deduction. Select or enter your agency below:

Select Agency

Other Agency Name

I authorize FLPBA to deduct from my personal account listed below the current monthly dues for membership. I understand deductions will be processed on the 5th of each month. This authority will remain in effect until such time as I provide written notice to FLPBA to terminate. I can stop payment at any time.

Bank Name

ACH Routing Number

Bank Account Number

I authorize FLPBA to deduct from the credit/debit card listed below the current monthly dues for membership. I understand deductions will be processed on the 5th of each month. This authority will remain in effect until such time as I provide written notice to FLPBA to terminate. I can stop payment at any time.

Name on credit/debit card

Billing address for card

City

State

Zip Code

Credit/Debit card number

Expiration Date

CVV/Security Code

Please check if you prefer to make a one-time yearly payment processed upon receipt and receive a 10% discount.

I direct FLPBA to mail a monthly billing statement to the address provided in the application.

Electronic Signature

By selecting the "Send" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual and/or handwritten signature on this Agreement. By selecting "Send" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. My signature hereon is authorization to release my social security number when reporting dues deductions.

Print Your Full Name:

Today's Date:

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Florida Police
Benevolent Association

Address

Dr. David Murrell Building 
300 East Brevard Street 
Tallahassee, Florida 32301

Contact Info

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