Washington Staff Assault Task Force

P.O. Box 363, Olympia, WA 98504 (509) 301-8874

As a member of WSATF, I receive a Benefit in an issuance of a $10,000 Life Insurance Policy. I hereby certify that I am a member of Washington Staff Assault Task Force (WSATF). If not a member, I am making application for membership in WSATF and authorize the Washington State Controller to deduct from my salaries and wages the amount specified now or in the future for membership dues. This authorization will remain in effect until canceled by me or the organization at my written request. I certify that I am a member of the above named organization and understand that termination of membership will cancel all deductions and benefits under this authorization. I authorize WSATF to collect the monthly minimum ($12.00) dues amount for my membership. Upon Washington D.O.C. retirement, I agree to become a ($10.00) per month WSATF Associate Member.



Email Address:	required
New application or Updating application information?:	required
First Name:	required
Last Name:	required
Phone:	required
Gender:
Address:	required
Address 2:
City:	required
State:	required
Zip/Postal Code:	required
Member nine-digit SSN:	required
Birthday:	required
WSATF Institutions:	required
Beneficiary Name:	required
Beneficiary Gender:	required
Beneficiary Birth Date:	required
Beneficiary Address:	required
Beneficiary Relationship:	required
Please Enter Your Name as Electronic Verification of Your Application:	required
Referred By: