Please check all that applies :

Career Firefighter: ________   Volunteer Firefighter: _________

□     New Member

□     Withdraw of Membership

□     Address Change

□     Name Change

Complete ALL fields in this section:

Name:______________________________


Spouse Name:_____________________________

Number of Children: _______

Address:________________________________________________________

City: __________________________State: ______ Zip Code: _____________

Home Phone: (_____)____________ Cell Phone: (_____)________________

Email Address:________________________________________________________

I, _________________________, do hereby apply for membership to the Sarasota Fire Fighter’s Benevolent Fund. I agree to abide by the By-laws of the organization and conduct myself in a manner befitting.

Signature_______________________________

OFFICAL USE

Received and Filed By: _______________________ Date:  ______________ 

Sent to Payroll By: ____________________________Date: _______________

Payroll Deduction Request

I, _________________________, would like to request a Payroll Deduction in the following amount of $5.00 per pay check for membership dues to the Sarasota Fire Fighter’s Benevolent Fund. I understand that the amount will be deducted from my payroll bi-weekly. 

 ___________________________________          _________________         
               Employee Signature                                          Date


  __________-_________-___________    
   Employee Social Security Number                                      

Send to: Sarasota County

                  1660 Ringling Blvd.

                  HR 4^th Floor

                  Sarasota, FL 34234