2007 – ACTIVE NEW MEMBER: $30.00
RENEWING MEMBER: $25.00
RENEWING MEMBER: $30.00 (After 1/1/07)
MEMBERSHIP APPLICATION - ACTIVE MEMBER
FRATERNAL ORDER OF POLICE
Nassau County Lodge 25, Inc.
PO Box 787, Mineola, NY 11501
Name: _______________________ MI: _____ Last: _______________________ Date of Birth: _____________
Street Address: _______________________________________________________________
City: ______________________________________ State: _______ ZIP: ________________
Home Phone: _____________________ Work Phone: ____________________ Other: __________________
E-Mail Address: __________________________________________
Beneficiary (Full Name): _______________________________________ Relationship: __________________
Department/Agency: _______________________________ Command/Unit: ___________________________
Rank/Title: _________________________ Active or Retired: _____________________
Circle One: New Member Renewing Member Returning Member
(Include photocopy of ID) (If you were a member last year) (If membership lapsed more than 1 year)
How (or by whom) were you referred you to Lodge 25?
Membership in the New York State Fraternal Order of Police Nassau County Lodge 25, Inc. is open to any regularly
appointed or elected full-time, or retired, sworn law enforcement officer with arrest powers who is employed by the
United States, or a state, city, town, village or political sub-division therein.
I HEREBY DECLARE THAT I AM A FULL-TIME OR RETIRED FULL-TIME LAW ENFORCEMENT OFFICER WITH
ARREST POWERS EMPLOYED BY THE UNITED STATES, OR A STATE, CITY, TOWN, VILLAGE OR POLITICAL
Signature: ___________________________________________________ Date: _______________________
|A photocopy of your law enforcement ID Card (active or retired) or letter from employer on official letterhead
verifying your current law enforcement status is required with this application!
All categories, whether you are active or retired, must be completed for your application to be considered!
A 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.