Membership Application

NEVADA STATE LAW ENFORCEMENT OFFICERS' ASSOCIATION
145 Panama Street, #11, Henderson NV 89015 (702) 813-7409

Applicant's Name:  
NEATS Number:
Last 4 SSN:
Agency:
Date of Hire:
Title:
Grade/Rank:
Sex:
Marital Status:
DOB:
Work Address:
City, State: ,
Zip Code:
Residence Mailing Address:
City, State: ,
Zip Code:

Cell Phone:
Home Phone:
Work Phone:

Home Email Address (*PREFERRED*):  
Work Email Address: 

I recognize that the NEVADA STATE LAW ENFORCEMENT OFFICERS' ASSOCIATION is not affiliated with my employer and/or the State of Nevada.
Applicant's Signature:
Date of Application:
Referred By:
NSLEOA - AUTHORIZATION FOR PAYROLL DEDUCTION:
Employee Name:
Employee I.D. NEATS Number/SSN:
Deduction Type Action: add
Deduction Amount: $42.00 per month
Misc. Info: I hereby authorize my payroll center to deduct from my salary the membership dues and benefit program payments in effect at this time or as modified in the future. In the event of a payroll deduction problem, I agree to the current policy on special payroll checks, which may change without notice. This request will remain in effect until cancelled in writing by either the employee or by the Nevada State Law Enforcement Officers' Association. 
Employee Signature: 
Date:

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