Print this form out, complete the information, and mail to the RPEA address shown below. It's that easy to join! Don't forget to attach your check or indicate alternate payment method. Thank you.

(PLEASE PRINT)

Revised 1/99

RETIRED PUBLIC EMPLOYEES' ASSOCIATION
300 T Street, Sacramento, CA 95814-6912
(916) 441-7732 or (800) 443-773
MEMBERSHIP APPLICATION

Name:________________________________  S.S. #_______________________

Spouse_______________________________

Mailing Address_____________________________City_____________________________

State_________ ZIP________________________

Phone: ( ______ ) __________________________

Category of Membership (Check One):

Retiree Beneficiary of Retiree	(Name of State Dept., shool district, counties, cities, or special district) Retired from____________________________________________________
Affiliate Associate	Currently Employed by____________________________________________	Chapter #
I authorize the Public Employees' Retirement System to withhold from my retirement allowance, deductions for RPEA dues: $3.00 per month for my RPEA dues**. $6.00 per month for myself plus Associate dues for my spouse**
When I wish this deduction terminated I will file such a request in the office of Retired Public Employees' Association. I understand that CalPERS cannot process a termination notice received directly from me and excess deductions, taken in error, will be returned to me by the Retired Public Employees Association. Signed:__________________________________________________________________________ Date:_________________________________________________ Under current tax laws, dues are not tax deductible I prefer paying the full dues for myself now. $36.00 enclosed Plus Associate dues for my my spouse. $36.00 enclosed (For two of you, $72.00/Year. Consider monthly payroll deduction) Prorated amount enclosed.