Join the Peralta Retirees Organization

To join PRO, please enter the information on the form below and then print the page. Enclose the completed printout with your check made out to Peralta Retirees Organization.

Name:
Spouse's Name:
Address:
City, State, Zip:
Years of Service:
Date of Retirement:
Phone:
Phone (Cell):
FAX:
Email:
Preferred Method of contact: Email US Mail
Institutions (Check all that apply): COA Laney Merritt Vista District Feather River

Please indicate your classification(s) when you were employed by Peralta:

Faculty
Staff (SEIU)
Staff (Local 39)
Administration
Board Member

Please indicate your classification at retirement (choose one):

Faculty
Staff (SEIU)
Staff (Local 39)
Administration
Board Member

Please indicate any contact information that you would like listed in the PRO Member Directory:

Address
Phone
Phone (Cell)
Email Address


Unless you authorize PRO to list your contact information in the Member Directory, no contact information for you will be available on the PRO Website.

 

Please identify your current health plan:

CoreSource
Kaiser

Are you enrolled in Medicare?

Yes
No

Mail your completed form and your check to:
Jerry Herman
PRO
1250-I Newell Avenue, #162
Walnut Creek, CA 94596