APPLICATON FOR MEMBERSHIP AND AUTOMATIC PAYMENTS
FOR THE PINAL COUNTY DEPUTIES ASSOCIATION AND AZCOPS
AUTHORIZATION AGREEMENT FOR AUTOMATIC PAYMENTS (ACH DEBIT)
ASSOC. NAME: AZCOPS 7077 / PINAL COUNTY DEPUITES ASSOCIATION
Association Monthly Dues: $ 25.00 
[ ]
($20.00 for civilian employees) [ ]
I (we) hereby authorize AZ COPS 7077, here in called COMPANY, to initiate debit entries and to initiate, if necessary, credit/debit entries and adjustments for any entries in error to my (our) account
[ ] checking or
[ ] savings account (check one)
indicated below at the BANK/CREDIT UNION named below, hereinafter called the DEPOSITORY, to credit or debit the same such account.
DEPOSITORY (Bank or Credit Union)
BANK NAME _________________________BRANCH # _____________
CITY _____________________ STATE _____TEL# (___)___________
ACCOUNT # _________________________
ROUTING # __________________________
This authorization is to remain in full force and affect until COMPANY has received written notification from me (or either of us) of its termination in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
NAME ___________________________________________________________
(Please print)SIGNATURE:_____________________________________DATE:___________
ADDRESS: ______________________________________City_________________ZIP___________
Home Phone:______________________ e-mail: ___________________________________________
Job Title: __________________________________________(Deputy/Detention Officer/Civilian)
ATTACH CHECK WRITTEN TO:
AZCOPS
FOR YOUR FIRST MONTH DUES
Mail the check and the above form to:
AZCOPS
333 W. Ft. Lowell, Ste 211
Tucson, AZ 85705
This temporary dues collection service is offered by AZCOPS while payroll deductions are established. Once payroll deductions are established for your Association, this services is automatically terminated.
(DUES ARE COLLECTED THE WEEK OF THE 20TH OF EACH MONTH)
