NSLEOA

Member Application Non - Payroll Deduction

NEVADA STATE LAW ENFORCEMENT OFFICERS' ASSOCIATION
145 Panama Street, Henderson NV 89015 (702) 813-7409

Applicant's Name:
NEATS Number:
Last 4 SSN:
Agency:
Date of Hire:
Title:
Grade/Rank:
Sex:
Marital Status:
DOB:
Work Address:
City, State:	,
Zip Code:
Residence Mailing Address:
City, State:	,
Zip Code:

Cell Phone:
Home Phone:
Work Phone:

*Home Email Address (PREFERRED):*
Work Email Address:

I recognize that the NEVADA STATE LAW ENFORCEMENT OFFICERS' ASSOCIATION is not affiliated with my employer and/or the State of Nevada.
Applicant's Signature:
Date of Application:
Referred By:
By submitting, I hereby designate the Nevada State Law Enforcement Officers Association and Nevada Association of Public Safety Officers / CWA Local 9110 AFL-CIO as my exclusive collective bargaining representative, to represent me in all matters pertaining to my employment with the State of Nevada, and to assert my rights under all contracts, policies, procedures and laws within their discretion.