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Online Application

PBA members are billed monthly for membership dues, the Palm Beach County Police Benevolent Association offers several billing options.

For additional information and/or questions about joining contact us toll free at (561) 689-3745.

Palm Beach County Police Benevolent Association Membership Application

Social Security Number (required)

First Name (required)

Last Name (required)

Employing Agency (required)

ID Number

Home/Mailing Address (required)

City (required)

State (required)

Zip Code (required)

Home/Cell Phone Number (required)

Date of Birth (required) MM/DD/YYYY

Date of Employment (required) MM/DD/YYYY

Rank or Position Title (required)

Personal (Non-work) E-Mail Address (required)

Member Dues Billing Options (Pick One)

Bank Draft - I authorize PBCPBA to deduct from my personal account listed below the current monthly dues for membership. I understand deductions will be processed on or about the 1st of each month. This authority will remain in effect until such time as I provide written notice to PBCPBA to terminate. I can stop payment at any time.

Bank Name

ACH Routing Number

Bank Account Number

Credit Card - I authorize PBCPBA to deduct from the credit/debit card listed below the current monthly dues for membership. I understand deductions will be processed on or about the 1st of each month. This authority will remain in effect until such time as I provide written notice to PBCPBA to terminate. I can stop payment at any time.

Please select if you prefer to make a one-time yearly payment processed upon receipt and receive a 10% discount.

Name on credit/debit card

Billing address for card

City (required)

State (required)

Zip Code (required)

Credit/Debit Card Number

Expiration Date (MM/YYYY)

CVV/Security Code

Individual Billing - I direct PBCPBA to mail a monthly billing statement to the address provided in the application.

Payroll Deduction - I direct my employing agency to deduct from my wages the appropriate PBCPBA dues in accordance with collective bargaining or other agreement between PBCPBA and the agency, if available. This authority will remain in effect until such time as I provide 30 days written notice to PBCPBA and the agency to terminate said deduction.

I hereby authorize Employing Agency (required)
to deduct from my wages each pay period the current regular PBA dues and transmit this amount to the Treasurer of the Palm Beach County Police Benevolent Association.

First Name (required)

Last Name (required)

ID# or Last 4 of SSN: (required)

Electronic Signature

By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual and/or handwritten signature on this Agreement. By selecting "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. My signature hereon is authorization to release my social security number when reporting dues deductions.

Print Your Full Name:

Today's Date (MM/DD/YYYY):

Online Application

Palm Beach County Police Benevolent Association Membership Application

Member Dues Billing Options (Pick One)

Electronic Signature

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