LASD MEMBERS Name 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 Do you currently have an open investigation or situation? * Yes No 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.