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.
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