PSP Retirees Association Application – PSP Retirees Association (PSPRA)

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Current Date

Registration Type(Required)

Retired PSP Enlisted Member

Retired Liquor Enforcement Officer

Retired Civilian Employee

First Name(Required)

Middle Name(Required)

Last Name(Required)

Suffix

Preferred Nickname

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Home Phone(Required)

Cell Phone

Any other surname used during PSP employment (e.g., maiden, married)

Honorable Separation Verification(Required)

I hereby verify that I received an honorable separation from the Pennsylvania State Police and apply for membership in the Retired State Police Association of Pennsylvania, Incorporated.

Date of Birth(Required)

Date of Enlistment or Employment(Required)

Date of Honorable Separation and/or Retirement(Required)

Honorable Paperwork

Enlisted Only: You must submit a copy of honorable separation paperwork.

Max. file size: 30 MB.

Spouse's Name

Date of Marriage

Your Enlisted Badge #(Required)

Officer Badge #(Required)

Cadet Class #(Required)

Rank and Position at Time of Retirement(Required)

Last Duty Troop/Station or Bureau/Division(Required)

Last Commanding Officer / OIC(Required)

I would like to pay for # year(s) of membership(Required)

Please enter a number greater than or equal to 1.

Mail A Check

I would like to mail a check

PSP Retirees Assocation Membership

Total

Credit Card(Required)

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