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)
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