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
                                                                     (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: __________________

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 Qualifications

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
SUB-DIVISION THEREIN.

Applicant
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.