PSP Retirees Association Application < Back Looking for a printable application? Download it here. Registration Type(Required) Retired PSP Enlisted Civilian Employment First Name(Required)Last Name(Required)Address(Required) Street Address Address Line 2 City State *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Home Phone(Required)Cell PhoneAny other surname used during PSP employment (e.g., maiden, married)Date of Birth(Required) MM slash DD slash YYYY Spouse's NameDate of Marriage MM slash DD slash YYYY Date of Enlistment or Employment(Required) MM slash DD slash YYYY Date of Honorable Separation(Required) MM slash DD slash YYYY Honorable PaperworkMax. file size: 30 MB.Your Enlisted Badge #(Required)Your Enlisted Badge #(Required)Your Enlisted Badge #(Required)Rank and Position at Time of Retirement(Required)Last Duty Troop and Station(Required)Last Commanding Officer / OIC(Required)Honorable Separation Verification(Required) I hereby verify that I received an honorable separation from the Pennsylvania State Police and apply for membership in the Retired State Police Association of Pennsylvania, Incorporated. I would like to pay for # year(s) of membership(Required)Please enter a number greater than or equal to 1.Mail A Check I would like to mail a check PSP Retirees Assocation MembershipTotal Credit Card(Required) CAPTCHA
