Retiree Membership Application

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– Step 1 of 2

Please select an option to continue: *

New Membership
Existing Member Dues Renewal (Cash only)

Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Mailing Address (If different)

Address Line 1

City

State

Zip Code

Email *

Home Phone

SSN Last 4 Digits *

Cell Phone

Retirement Plan *

Agency Retired From

Retirement Date

Recruited By/How did you hear about us?

Birth Date

Dues Payment Method *

Automatic Dues Deduction via DRS Pension
Credit Card

Select Membership Option *

Retiree or Surviving Spouse ($7/mo)
Retiree & Spouse/Partner ($14/mo)

Spouse/Partner Name (If Selecting Retiree & Spouse/Partner Option) *

First

Last

Sign Here to Authorize Automatic Deduction via DRS Pension *

Clear Signature

I authorize the Department of Retirement Systems (DRS) to regularly deduct a sufficient amount from my retirement allowance to pay the amount required for my union/organization dues at my request, under this program. Deductions will continue until the deduction plan is canceled through the union/organization office. I understand that DRS cannot answer questions about my union or organization. RPEC is 501c5 organization. Dues are not tax deductible.

Authorization *

I have read the above statement and agree to its terms.

Membership Option: *

Dues are charged at an annual amount of $84 for retiree or surviving spouse, and $168 for retiree & spouse/partner.

Spouse/Partner Name (If Selecting Retiree & Spouse/Partner Option) *

First

Last

Total to be Charged:

Item Quantity Qty Total

There are no products selected.

Membership Option: – Annual Dues (Retiree Only) 1 $84.00

Membership Option: – Annual Dues (Retiree & Spouse/Partner) 1 $168.00

Subtotal

Total $0.00

$0.00

Credit Card Payment via Square *

Card

Name on Card

By clicking on the Submit button below, I authorize the Retired Public Employees Council of Washington (RPEC) to charge the credit card entered above, the amount required for my membership dues, as indicated by my selection. RPEC is a 501c5 organization and dues are not tax deductible.

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