Coupons
APPLICATION FOR BOOSTER
PLEASE PRINT BOOSTER APPLICATION PLEASE PRINT
Please insert the following booster(s) in the newsletter. Each Booster costs $5 & will run for one year starting with the next issue. Be sure to include your name as the “DONOR”. Make checks payable to FDNY Retired, Mail to: FDNY Retired, Box 76, Port Richey, Fl 34673-0076
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Donor’s Name_______________________________________________________________________________________
APPLICATION FOR MEMBERSHIP IN THE GENE OKANE DIVISION OF FDNY RETIRED
GENE OKANE DIVISION OF FDNY RETIRED
POST OFFICE BOX 76 – PORT RICHEY, FL. 34673-0076
Please print all information
Name___________________________________________________________________________________________
Address_____________________________________________________Date Of Birth________________________
City_____________________________________________________State________________ Zip_______________
Phone__________________________________Email____________________________________________________
Badge #___________Rank_________Pension Number (include all letters & numbers)_____________________
Date Appointed__________________________________To Unit__________________________________________
Date Retired_____________________________________ From Unit_______________________________________
Units Worked In __________________________________________________________________________________
Retired (check one): For Service _________ Ordinary Disability_________Line Of duty Disability __________
Do you pay retirement dues to UFA or UFOA? Yes_______ No_________
Wife’s Name___________________________________Wife’s date of birth ________________________________
Email address if any ___________________________________________
Summer address if applicable & dates you will be there:
Address_________________________________________________________________________________________
City_______________________________________State_______________ Zip______________________________
Phone_____________________________ Email (if different)____________________________________________
Dates you will be there ______________
Mike Doyle , Financial Secretary
7102 Grand Blvd., New Port Richey Fl, 34652
(727) 819-8824
Please include a check for $25 ($20 for dues, $5 for Widows/Survivors Fund)
Make check payable to: FDNY Retired