PBA Application

Online PBA Application - Bank Draft, Credit Card & Direct Billing

Florida Police Benevolent Association Membership Application

Social Security Number (required)

Employer # or People's First ID #

First Name (required)

Last Name (required)

Employing Agency (required)

Institution/Troop/Region/Division, if applicable

Home/Mailing Address (required)

City (required)

State (required)

Zip Code (required)

Home/Cell Phone Number (required)

Date of Birth (required) MM/DD/YYYY

Date of Employment (required) MM/DD/YYYY

Rank or Position Title (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:

Member Dues Billing Options (Pick One)

Bank Draft - 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

Credit Card - 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.

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

Name on credit/debit card

Billing address for card

City (required)

State (required)

Zip Code (required)

Credit/Debit Card Number

Expiration Date (MM/YYYY)

CVV/Security Code

Individual Billing - 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 (MM/DD/YYYY):

Online PBA Application - Bank Draft, Credit Card & Direct Billing

Florida Police Benevolent Association Membership Application

Recruitment Information - If Applicable

Member Dues Billing Options (Pick One)

Electronic Signature

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