Orange County NC Website
Browse       Search
3 <br /> 2010 ADDITION/DELETION FORM <br /> To: N C State Firemen's Association c �� <br /> 323 West Jones Street, Suite 401 IF T] <br /> Raleigh,NC 27603 <br /> B C�j�6t1► ,S luzgncsfa.com or sandie@a,ncsfa.com <br /> Fire Department Name L y {�eLil Telephone (919) 821-2132 <br /> 51D AAe_c atn-AcAM Toll Free 1-800-253-4733 <br /> Address Fax(919) 821-9382 <br /> r- <br /> ADDITIONS: <br /> X V I D J'YJ.:�CS- <br /> Name Social Security Number DO 2-1/x-- <br /> Phone Number <br /> Address E-mail Address <br /> /// /-,-7 <br /> Effective bate <br /> al Female Married Single Paid/Volunteer/Retired <br /> DELETIONS: <br /> /y 7- <br /> Name Name <br /> Name Name <br /> Chief Signature a <br /> You may add one member for each member deleted at no charge. There is a membership fee of$17.00 for all <br /> other members added. You have 30 days to send in membership dues if you fax this information in. It is <br /> understood that no claims will be paid against this New Member until membership dues are received in our <br /> office. After 30 days, if no membership dues are received,this New Member will not be covered. <br /> Department may duplicate this form. <br /> Effective January 1,2010 <br />