KCDOA Membership Application

        I authorize KCDOA to have deducted from my salary, the amount of my dues and any other payroll
deductions I have authorized in writing. I agree to pay dues in accordance with the schedule adopted by the
KCDOA Board of Directors (or KCDOA Officers in the absence of a Board).

        I wish to have KCDOA and/or their affiliated organizations represent me in all matters within their legal
scope of representation.

Print Name _______________________________________	Employee Signature __________________________________
Mailing Address ___________________________________	City ___________________________ Zip ________________
Home Phone _____________________________________	Cell Phone _________________________________________
Email Address _______________________________________________________________________________________
Date Of Hire ______________________________________	Date Of Birth _______________________________________
Work Location (Facility) _____________________________	Work Hours (Squad #) _______________________________
County Employee ID Number:	__________________________________________________
	(999-xx-xxxx from SheriffNet & pay stub - NOT CAD ID#)
Date ____________________________________________	Circle Your Classification: Line Staff / Senior / Sergeant

Kevin Dees	[ Max-Med Squad 1 ]
Sr. Scott Robinson	[ Max-Med Admin ]
Anthony Leal	[ Compliance ]
Amanda Van Allen	[ Pre-Trial Squad 2 ]
Sgt. Todd Dearmore	[ Max-Med Admin ]
Phil Morley	[ Max-Med Utility ]
Martin Santillan	[ Work Release ]