2007 – ASSOCIATE                                                                                            NEW MEMBER:   $35
                                                                                                             RENEWING MEMBER:   $30
                                                                                                             RENEWING MEMBER:   $35   (After 1/1/07)


                       
MEMBERSHIP  APPLICATION  -  ASSOCIATE  MEMBER

                                                      FRATERNAL ORDER OF POLICE
                                                              Nassau County Lodge 25, Inc.
                                                            PO Box 787,  Mineola, NY 11501
                                                                          (718) 426-9660


First
Name: _______________________ MI: _____  Last: _______________________ Date of Birth: _____________


Street Address: _______________________________________________________________


City: ______________________________________  State: _______   ZIP: ________________


Home Phone: _____________________  Work Phone: ____________________  Other: __________________


E-Mail Address: __________________________________________


Beneficiary
(Full Name): ________________________________________  Relationship: __________________


Sponsored By: ___________________________________________


Circle One:                New Member                        Renewing Member


Applicant
Signature: ___________________________________________________   Date: _______________________
All categories must be completed for your application to be considered!

Only one contact phone number is required.  Additional phone numbers and e-mail address are optional.

* MEMBERSHIP IS VALID FROM JANUARY 1st  TO DECEMBER 31st  *

Please remit check or money order payable to:        FOP Lodge 25, Inc.