Retired Scdps Membership Form

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South Carolina 
Troopers Association 
Retired SCDPS 
Membership Form w/ P4 
All fields are required. Those marked in ORANGE are conditional. Once completed, either 1) print 
and mail this form to 4961 Broad River Rd, Columbia SC 29212 or 2) fax it to 803‐772‐1125. Because 
this form contains your sensitive information and because your signature is needed, we strongly en‐
courage you to print and mail it via the US Postal Service instead of emailing it to us. 
 
Once your Retired status has been verified, we will contact you at your preferred email address. 
 
Please note: If you haven’t already done so,. 
Your Retired SCDPS Membership will entitle you to a 20% discount on all purchases and you will be 
given access to restricted items/resources. If you have already created an account, remember to let 
us know what your username is in the appropriate area below. 
 
‐‐ Dues are not tax deductible ‐‐ 
‐‐ Any ongoing investigations at the time of this application will not be covered by the Association’s legal defense fund ‐‐ 
1. SCDPS‐SPECIFIC INFORMATION 
Rank at Retirement: ________________________  Date of Retirement: _______________________ 
SCDPS Division (HP, BPS, STP) & Troop/Region: ___________________________________________
 
 
2. MEMBER‐SPECIFIC INFORMATION 
Last Name: _________________________  First Name: _________________________  MI: _______ 
Mr. or Ms./Mrs.: ________ Preferred Email Address: ______________________________________ 
Birthdate: __________________________  Social Security Number: __________________________ 
Street:  ___________________________________________________________________________ 
City: ________________________  State:  ____   Zip: ___________  Phone: ____________________ 
sctroopers.org Username: __________________________________ 
(Haven’t signed up yet? Type ‘NA‘) 
Is this a:              ____ New,              ____ Renewal, or              ____ Updated App 
 
(Type ‘X’ beside which)
(continued on page 2) 

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