Long Island Association of Retired New York City Firefighters
APPLICATION FOR MEMBERSHIP – Use it or give it to a friend (Please print in block letters)

Your Name____________________________________________

Spouse’s First Name_____________________________

Address________________________________________City___________________State_____Zip+4______

Phone _______________________DOB ____________

Date Appointed ______________ Date Retired____________ Rank__________________

Are you Active______ or Retired ______?

Retired for: Service_______or Disability______ SC ____/Non-SC ____

Email address____________________________________________________

Will you volunteer to help our organization? Yes ______ No ______

Your check #____________

2023 Membership/Renewal is $50*
*Dues paid by 12/31/22 will be at the old rate of $30. This is a one-time offer!
Make check payable to L.I. Association of Retired NYC Firefighters and mail to:
L. I. Association of Retired NYC Firefighters, PO Box 793, Centereach, NY 11720-0793#