Payroll Deduction - Esignature

Florida Police Benevolent Association Membership Application

Social Security Number:

Employee ID:




Address: , ,



Date of Employment:



Payroll Deduction Billing:

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.

Selected Agency:

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:

Electronic Signature:

You agree your electronic signature, below, is the legal equivalent of your manual and/or handwritten signature on this Agreement. By signing electronically 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.

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Signature Certificate
Document name: Payroll Deduction - Esignature
lock iconUnique Document ID: 976c2b27e3e138d0eaf9dab910d1ac08acd202e7
Timestamp Audit
March 21, 2023 8:11 pm EDTPayroll Deduction - Esignature Uploaded by Sherry Hannon - IP
March 23, 2023 2:21 pm EDTSherry Hannon - added by Glenda Lowery - as a CC'd Recipient Ip:
March 28, 2023 7:17 pm EDTSherry Hannon - added by Glenda Lowery - as a CC'd Recipient Ip:
June 15, 2023 8:09 pm EDT Document owner has handed over this document to 2023-06-15 20:09:48 -