Registration Form

Dues Payment for July 2023 to June 2024

Membership in the Coalition is a privilege and not a right. All Membership decisions are subject to the sole and absolute discretion of the Board of Directors. Conviction of a felony, of a crime involving moral turpitude or behavior which would discredit the Coalition may be grounds for rejection of a Membership application or modification or termination of Membership status.

Please Check One*
- Existing Member
- New Member
Name*
First Last
MI
Badge #
Email*
Date of Birth*
Spouse Name

(If you are a surviving spouse, please indicate retiree’s name/badge)
Mailing Address*
City*
State*
Zip*
Home Phone
Cell Phone
Work Phone
Okay to release above info to Coalition members or other DPS retirees?*
- Yes
- No
Annual Dues (required)*
Price:
Dues for next fiscal year (July 2021 to -June 2022)
Additional Donation Amount (optional)

Enter your additional tax deductible donation in the space above in the amount of your choosing.
YOU ARE NOT DONE YET!!!!! To finalize registration or dues payment, Click “Submit & Pay Dues” to be taken to our secure PayPal page where you can enter your credit card information. Note: It is strongly recommended that you do NOT select the PayPal credit option. Use your own credit card or checking account number if you do not have a PayPal account. Any questions, call Ed Felix (602) 717-1900
Email
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CDPSR

Coalition of DPS Retirees, Inc

Registration Form

Dues Payment for July 2023 to June 2024