RETIREMENT ITEMS SHOULD BE MAILED TO YOU WITHIN 3 MONTHS FROM OUR RECEIPT OF THIS FORM.
First Name:
Middle Initial:
Last Name:
Position:
Department:
Badge Number (if applicable):
Mailing Address:
Phone Number:
Email:
Retirement Date:
Years of Service (including bought military and other dept.)
Do you want to have a picture for the Police Beat Magazine?
YesNo
Do you want to remain an OPBA member?
