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Washington Staff Assault Task Force TM
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MEMBERSHIP APPLICATION

 

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First Name
Last Name
Member Birth Date
Beneficiary Full Name
Beneficiary Birth Date
Relationship to Beneficiary
Member Email
Member Address
City, ST, ZIP
Member Contact Number
Member Complete SSN
Agency/Institution

As a member of WSATF, I receive a Benefit in an issuance of a $10,000 Life Insurance Policy.

I hereby certify that I am a member of Washington Staff Assault Task Force (WSATF). If not a member, I am making application for membership in WSATF and authorize the Washington State Controller to deduct from my salaries and wages the amount specified now or in the future for membership dues. This authorization will remain in effect until canceled by me or the organization at my written request.

I certify that I am a member of the above named organization and understand that termination of membership will cancel all deductions and benefits under this authorization. I authorize WSATF to collect the monthly minimum ($12.00) dues amount for my membership. Upon Washington D.O.C. retirement, I agree to become a ($5.00) per month WSATF Associate Member.

For more information, please review the WSATF Web site Legal Notice and Privacy Policy.

Copyright 2011 Washington Staff Assault Task Force TM -- All Rights Reserved. P.O. Box 905, Walla Walla, WA 99362 Tel (509) 301-8874 Email