Membership Application

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.
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Date of Birth*
MM slash DD slash YYYY
Last 4 digits of SSN*
Phone*
E-mail*
Gender:*
- Male
- Female
County Dept. Retired from:*
Retirement Date*
MM slash DD slash YYYY
Select Your Membership Type:*
- Retiree Only ($2.50/Month)
- Retiree & Spouse/Partner ($3.50/Month)
Spouse Name*
Spouses Birthday*
MM slash DD slash YYYY
Authorization
- 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?
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