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
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Received by:*
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Date Received:*
MM slash DD slash YYYY
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Auditor system access by:*
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Auditor system access date:*
MM slash DD slash YYYY
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FOP web site:*
Comments
This field is for validation purposes and should be left unchanged.