Membership Application "*" indicates required fields Please fill out the form below to join RELAC. If you prefer to download the form to print and mail via USPS, please click here. This form requires cookies, please make sure you are not blocking cookies for this site or the form may not work correctly!Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Date of Birth* Month Day Year Last 4 digits of SSN*Phone*E-mail* Gender:* Male Female County Dept. Retired from:*Retirement Date* Month Day Year Select Your Membership Type:* Retiree Only ($5.00/Month) Retiree & Spouse/Partner ($7.00/Month) NOTE: If spouse/partner is also a County retiree, (s)he must also join as a retiree member (two memberships = $10/month).Spouse Name*Spouses Birthday* MM slash DD slash YYYY This field is hidden when viewing the formAuthorization I authorize LACERA to deduct my monthly dues from my retirement check and pay that amount to RELAC. RELAC E-mails Keep me posted - I want to receive periodic RELAC e-mails and notices concerning topics of importance to me. Save paper - I want to receive the RELAC newsletter by e-mail only. How did you hear about RELAC?By submitting this form, you elect to join RELAC and authorize LACERA to deduct from your retirement check: (1) Your monthly dues and pay that amount to RELAC: (2) If applicable, your voluntary insurance premiums and pay that amount to their respective insurance administrator.
