Kentucky Public Retirees
                              Membership Application Form

Dues are $15.00 but membership is free for the

balance of the year in which you sign up. 

Mail To: Kentucky Public Retirees

 P.O. box 21734  

 Lexington, KY 40522-1734

Name___________________________________________

Address____________________City__________________

State______Zip__________County____________________

Phone Home _________Chapter__________  

Referred by____________Date____________

E-mail Address_________________________