Membership Application

Membership Application

FOP Lodge #35
Date

MonthDayYear
Date
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
SS#*
Department*
Non-Department Email*
example@example.com
Phone Number*
Are you currently a member of another FOP Lodge?*

NoYes
Which lodge are you currently a member of?
Authorization for Payroll Deduction (CPD Only):
Signature*

Clear
Date of Authorization

MonthDayYear
Date
Beneficiary Form
Name of Member*
BENEFICIARY INFORMATION:
Name of Beneficiary*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
Date of Birth*

MonthDayYear
Date
Relationship*
SIGNATURE*

Clear
THIS IS KEPT ON FILE, INFORMATION IS NOT SHARED WITH ANYONE INCLUDING THE STATE/NATIONAL LODGE UNLESS THERE IS A NEED TO PROVIDE BENEFICIARY WITH DEATH BENEFIT ASSOCIATED WITH BEING A MEMBER OF THE FRATERNAL ORDER OF POLICE.
DATE

MonthDayYear
Date
ANNUAL DUES PAYMENT OPTIONS
Dues are $39/year
Annual Dues Payment Method*

Credit/Debit/PaypalCash/CheckVenmo
Cash or Check made to "Carrollton FOP"

Mailing Address:

Carrollton FOP, Attn: Amanda Moore

115 West Center Street Carrollton GA 30117
Venmo: @Carrolltonfop-35
CHECK THE BOX BELOW TO PAY DUES NOW
Annual Dues
prevnext( X )
FOP Annual Dues
$39.00

Total

$0.00
ALL PERSONAL INFORMATION IS HELD IN CONFIDENCE & WILL NOT BE RELEASED.

IF YOU WISH TO GO AHEAD AND SIGN UP FOR LEGAL COVERAGE, GO TO FOPLEGAL.COM, USE "00035" FOR LODGE NUMBER AND "PENDING" FOR MEMBER NUMBER. YOU CAN DO THIS AS SOON AS YOU SUBMIT YOUR FORMS; YOU DO NOT HAVE TO WAIT FOR YOUR CARD TO ARRIVE.
Should be Empty:

Membership Application

Beneficiary Form

BENEFICIARY INFORMATION:

ANNUAL DUES PAYMENT OPTIONS