RPEN MEMBERSHIP APPLICATION

Name:__________________________________________________
Address:__________________________________________________
City:__________________________________________________
State:__________________________________________________
Zip:__________________________________________________
Email Address:__________________________________________________
Check here if you DO NOT wish to receive emails from RPEN about important retiree issues.
Birthdate:__________________________________________________
Telephone:__________________________________________________
Last Public Employer:__________________________________________________
Spouse:__________________________________________________
Spouse's Birthdate:__________________________________________________

AUTHORIZATION:
I hearby authorize the Public Employees' Retirement System (PERS) to deduct monthly RPEN dues for me, OR for my spouse and me as I have designated below at the rate of $5 per person per month from (circle one)    MY   or    OUR    monthly PERS check(s). I understand this will continue in the amount established by RPEN until I notify RPEN in writing to discontinue the deduction(s).


Number of PERS check deductions at $5 each per month (check one):
Me
My spouse and Me

OR

I have enclosed $60.00 for the first year of dues and will receive an invoice for dues on an annual basis determined by the month I joined RPEN.

My retirement date:__________________________________________________
Spouse's retirement date:__________________________________________________
My signature:__________________________________________________
Spouse's signature:__________________________________________________

 

OR

 

I am enclosing a "Voided" Personal Check and would like to pay my monthly dues through the ACH (Automated Clearing House Electronic Deduction) from my personal checking account. Please note which method you prefer: monthly deductions of $5.00 OR annual deductions for $60.00.

 


In addition to our legislative efforts and informational bi-monthly newsletters your membership in RPEN provides you with a network of local chapters, one in each of 19 Nevada communities. These chapters meet on a monthly basis to hear speakers who make presentations on topics of importance to retirees. Members also have an opportunity for social fellowship.

Please circle the community whose chapter you wish to belong to:

Bi-Valley (Yerington)    Boulder City     Carson City    Churchill (Fallon)    Elko    Fernley    Henderson

High Desert( inactive)   Las Vegas   Lincoln (Caliente-Alamo-Pioche)    Mineral (Hawthorne)   

Northern Tri-County (Battle Mountain-Lovelock-Winnemucca)   Pahrump   Sparks   Summerlin  Tonopah   Two Rivers (Mesquite-Overton)   Washoe (Reno)   White Pine (Ely)

You can mail your application to RPEN, P.O. Box 2211, Carson City, NV 89702, or fax to (775) 882-6732 or turn it in at one of the above chapters.