Houston Police Retired Officers Association

HOUSTON POLICE RETIRED OFFICERS ASSOCIATION
RENEW REGULAR MEMBERSHIP

This form is only for Houston Police Department retirees, active HPD officers who are currently in the DROP program or the surviving spouses of one of these.
Please do not leave any of the below fields blank. Enter NA if not applicable.

First Name: (in full) *

Last Name: *

Cell Phone: *

Home Phone:

Email Address: *

HPD Employee #: *

Date of Birth: *

Home Street Address: *

City: *

State: *

Zip Code: *

Spouses Full Name:
N/A if not applicable: *

Date Retired or Date Entered into DROP:
N/A if not applicable: *

Membership Dues:

$75.00 Annual Dues

Optional One-Time Annual PAC Donation:
A voluntary PAC contribution of $25.00 or more is suggested. For those contributing with corporate funds, the donation will instead go to the Family Assistance Committee (FAC), rather than the PAC
$

Is the PAC Donation being made from a Corporate Account? *
Yes (Will go to FAC) No Not Applicable

PAC Donation Requirement per Texas Ethics Commission: *
Current Employer & Position, or if Retired, Last Position Held:

Optional TMPA Legal Defense: (If Yes $40 Fee) * This coverage is only available for Honorably Retired HPD Officers.

Yes ($40.00) No ($0.00)

Total Amount Due:
$

YOU WILL BE PROMPTED TO PRINT THIS FORM AFTER CLICKING "SUBMIT APPLICATION.
IF YOU ARE PAYING VIA CREDIT CARD - YOU DO NOT NEED TO PRINT / MAIL IN THE FORM.

You should receive an email confirmation within a few minutes. If not, please call the below phone number for assistance.

IF PAYING BY CHECK, MAIL PAYMENT AND SIGNED APPLICATION TO:

HOUSTON POLICE RETIRED OFFICERS ASSOCIATION
P.O. BOX 130787, HOUSTON, TX 77219
Call (713) 802-2967 or 1-866-856-7252 with any questions

Please sign below if you are submitting this form by mail.

Signature:

Method of Payment:
Pay By Check - Print Application and Mail Credit Card

Credit Card Information (all fields required)

Card Type

Cardholder's First Name

Cardholder's Last Name

Credit Card Number

Exp Date
(e.g.: 05/2021)
Security Code

Cardholder's Billing Street Address

Billing City

Billing State
(2-digit state code)
Billing Zip Code

Billing Country
(2-digit country code)