Registration Dues Payment for July 2022 to June 2023 Registration Renewal/New Member Application Form Please Check One* Existing Member New Member Name* First Last MI Badge # Email* Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse Name (If you are a surviving spouse, please indicate retiree's name/badge)Mailing Address* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip* Home PhoneCell PhoneWork PhoneOkay 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 PhoneThis field is for validation purposes and should be left unchanged.
