LELS / PORAC
RETIREE LDF Membership APPLICATION

Name

First Name

Last Name

Personal Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Were you an LELS Member?

Yes

Agency Retired From

P.O.S.T. Number

HR218 / LEOSA Certification Expiration Date

Active HR218 / LEOSA Certification required for membership

Dates of Desired Coverage

NOTE:
Upon receipt of this Legal Defense Fund Application, LELS will respond via email with payment instructions.

Legal Defense Fund Coverage is not activated until application has been approved and payment has been received.
Membership = $90 per year / $7.50 per month (Plan Year = January 1 - December 31) Partial months will not be prorated.

If you have any questions, please contact Connie Deans @ cdeans@lels.org or (651) 793-2323.

LELS / PORACRETIREE LDF Membership APPLICATION

LELS / PORAC
RETIREE LDF Membership APPLICATION