Please print out this application & fax it to (718) 937-3478 or mail it for enrollment.

NEW MEMBERSHIP APPLICATION

 

CIVIL SERVICE RETIRED EMPLOYEES ASSOCIATION

 

34-27 Steinway Street

3rd Floor

Long Island City, NY 11101

Tel: (718) 937-0290

Fax: (718) 937-3478

 

1.    NAME            __________________________________________________________

2.     ADDRESS      ______________________________________Apt # _____________

 

                          _______________________________________________________

 

3.    PRESENT or FORMER DEPARTMENT __________________________________

 

4.    TITLE  ________________________________________________________________

 

5.    AGE    ________________________________________________________________

 

6.    YEAR RETIRED or EXPECTED TO RETIRE _____________________________

 

7.    HOME TEL.# (        )____________________________________________________

 

8.    REMARKS  ____________________________________________________________

 

9.    Do you wish to have the CSREA $2,000,000 Catastrophe insurance

          application mailed  to you now? _________________ (Yes or No)

10.    Do you wish to have the CSREA limited medical insurance application

          mailed to you now?______________________________ (Yes or No)

     (The cost is only $12 per year!)

 

Dues are thirty five dollars ($35) per year.

Now we are accepting three major credit cards such as Master, Visa & American Express over the phone.

Or checks can be mailed to CSREA 34-27 Steinway Street , Long Island City, NY 11101.

Or would you like to pay four hundred dollars ($400) to be a life member and you will never have to pay anything again. Five hundred dollars ($500 via payout).

You must be a current or retired employee of NYC or NYS to join our association. Membership dues are not tax deductible or refundable.

You will also receive a car decal, a gold plated lapel pin, an identification card and card case after you have enrolled.

 

Credit Card Type (Please circle)

1.Visa            2. MasterCard        3.American Express

 

Name on the card    -------------------------------------------

 

Expiration Date (Month/Year)  ------------/-------------

 

Card Number   ----------------------------------------

 

Amount you want to pay $------------------

 

Your Signature agreed to pay the above amount  -----------------------

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