Name:
  
Address:
  
City:
  
State:
  
Zip:
  
Social Security Number:
  
Birthdate:
  
Telephone:
  
Last Public Employer:
  
Spouse:
  
Spouse's Social Security Number:
  
Spouse's Birthdate:
  

AUTHORIZATION:
I hearby authorize the Public Employees' Retirement System (PERS) to deduct monthly RPEN due for me, or for my spouse and me as I have designated below at the rate of $3 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 DEDUCTIONS: (circle one) @3.00 each per month
ME or MY SPOUSE AND ME
My retirement date:
  
Spouse's retirement date:
  
My signature:
  
Spouse's signature:
  


In addition to our legislative efforts and informational newsletters your membership in RPEN provides you with a network of local chapters, one in each of 15 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:

Boulder City   Caliente  Carson City   Elko  Ely  Fallon  Hawthorne  Henderson

Las Vegas  Pahrump  Reno  Sparks  Tonopah  Winnemucca  Yerington

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.