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4 <br /> 2010 ADDITION/ DELETION FORM <br /> To: N C State Firemen's Association <br /> 323 West Jones Street, Suite 401 <br /> Raleigh,NC 27603 <br /> luzgncsfa.com or sandie@rLicsfa.com <br /> Fire Department Name �_ ,� ,�y 1Y} 'r Telephone (919) 821-2132 <br /> 51t7 Toll Free 1-800-253-4733 <br /> Address Fax(919) 821-9382 <br /> ADDITIONS: <br /> Name Social Security Number DOB <br /> Phone Number <br /> Address r E-m Ad ess <br /> 0/%t Z <br /> Effective Dad <br /> Male/ emale Married Single ("Paii1 Volunteer/Retired <br /> DELETIONS: <br /> re-, � <br /> Name Name <br /> Name Name <br /> Chief Signature <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 />