KCDOA Membership Application

Print Name*
Mailing Address*
Street Address City ZIP / Postal Code
Email Address*
Phone*
Date of Hire*
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Work Location (Facility)*
Shift*
County Employee ID Number*

(999-xx-xxxx from SheriffNet & pay stub - NOT CAD ID#)
Employee Signature*
Date*
MM slash DD slash YYYY
Initials*

I authorize KCDOA to deduct from my pay, the amount of my dues and any other payroll deductions that I have authorized
Initials*

I agree to pay dues in accordance with the schedule adopted by the KCDOA Board of Directors.
Initials*

I wish to have KCDOA and/or their affiliated organizations represent me in all matters within their legal scope of representation.
Initials*

If I separate from the Detentions Deputy classification for any reason, it is my responsibility to notify KCDOA to stop my dues.
Initials*

KCDOA will only refund up to (2) two pay periods after separation from the Detentions Deputy classification.
OFFICE USE ONLY
Hidden
Received by:*
Hidden
Date Received:*
MM slash DD slash YYYY
Hidden
Auditor system access by:*
Hidden
Auditor system access date:*
MM slash DD slash YYYY
Hidden
FOP web site:*
Name
This field is for validation purposes and should be left unchanged.