I hereby designate Pinellas County Police Benevolent Association, Inc., as my collective bargaining representative, authorizing Pinellas County PBA or its agents or representatives to act for me as collective bargaining agent in all matters pertaining to rates of pay, hours, and other terms and conditions of employment. ______________________________________ (Print)Last Name _______________________________ First Name ____________ Middle Initial ___________________ Home Address ___________________ Street ___________________ City ____________ State ____________ Zip> ______________________________________ Classification and Rank _______________________________ Department ____________ Work Site State Law Requires that you SIGN and DATE Authorization for Representation ___________________________________ Signature ____________ Date __________________________________ Home Telephone Number Print this form, complete it, and mail it to: 14450 46th Street N, # 115 Clearwater, FL. 33762