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* 1. Department Name

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* 2. What is your Department's Employee Identification Number (EIN)?

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* 3. Chief's Name:

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* 4. Number of Full-Time Sworn Employees:

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* 5. What is your Email Address?

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* 6. What is your Phone Number?

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* 7. I agree to submit dues for 2019 as soon as possible through the website (OSPDA.org) or by mail. I understand that my membership will not be processed until the fee is received.

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