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NYPD 10-13 Club of Charleston - Intake Form
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Email
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Your email
Full Name
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Your answer
Address, City, State, Zip
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Your answer
Gender
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Choose
Male
Female
Phone Number
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Your answer
Spouse's Name & Phone Number
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Your answer
Email Address
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Your answer
Birthdate
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DD
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YYYY
NYPD Tax#
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Your answer
NYPD Appointment Date
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DD
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YYYY
NYPD Retirement Date
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DD
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YYYY
Mode of Retirement
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Choose
Service
Vested
Resigned
Ordinary Disability
Accidental Disability
Last Command
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Your answer
Last Rank Held
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For Associate Members Only: Other LEO Agency Name
Your answer
I declare my desire for membership to the 10-13 Club of Charleston, SC. I will submit my membership fee and regularly subscribe my renewal fee by the first of January each year to remain a member in good standing.
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I agree to the above statement.
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