LASD MEMBERS Order Number First Name * Middle Name Last Name * Rank * Unit of Assignment * Employee # * Home Address * City * State * Zip Code * Email * Cell Phone # * Home Phone # If you were referred by a co-worker, please enter their name so they can receive proper credit. Referred By Are you aware of any pending or possible administrative investigations against you? * Yes No Have you been involved in a 998 in the last year? * Yes No Have you been involved in a CAT III UOF in the last year? * Yes No Have you been advised that a POE has been filed against you in the last year? * Yes No Have you been ROD in the last year? * Yes No Have you been benched in the last year? * Yes No Have you been placed on Performance Review or Peer Mentoring in the last year? * Yes No Have you been involved in an on-duty TC in the last year? * Yes No If you answered “yes” to any of the foregoing, you agree by submitting this application, that LASPA has the right to withhold legal representation and/or payroll reimbursement benefits, relative to any incident that predates your joining LASPA. You Must Select One * Deputy Sheriff—-$70 Sergeant—-$70 Lieutenant—-$70 Reserve Deputies—-$225 for 1 Year Reserve Deputies—-$60 for 3 Months Custody Assistant—-$40 Security Officers—-$20 Security Assistants—-$15 Law Enforcement Technicians—-$23 Other If you selected Other, please specify below: Deductions Agreement I hereby authorize the auditor of the County of Los Angeles or his agents to deduct monthly from salary earned by me in any department or district of the County of Los Angeles, the amount shown hereon and to pay same to: The Los Angeles Sheriff’s Professional Association. If all or any portion of this deduction authorization includes insurance premiums and/or employee organization dues, I also authorize the auditor to adjust from time-to-time the amount of this deduction as may be required to comply with adjustments in county subsidy amounts or in premiums under existing contracts with said insurance plans, or to comply with dues schedules determined by said employee organizations’ governing body in accordance with such organizations’ constitution, charter, bylaws, or other applicable legal requirements. This authorization cancels and replaces any previously signed by me with this deduction agency for this purpose and shall remain in effect until canceled by me by written notice. I expressly understand and agree that the auditor, his agents, or the county acting under this authorization shall not be liable in any manner for failure or delay in making the deduction or payments here authorized. Agree Yes, I agree to the above terms and conditions.