Name:______________________________________________  Date of Birth: ______________

Address:____________________________________________

City:____________________ State:_________ Zip:_________ Home Phone:_______________

Department:____________________________________________________________________

Work Phone:__________________________ E-Mail Address:___________________________

Number of Children:______
Children(s) Name(s):                                                                                     Date of Birth

_______________________________                         _____________
_______________________________                         _____________
_______________________________                         _____________
_______________________________                         _____________
(If more room is needed, use the back of this form)


I hereby appoint ________________________________, address ______________________________as my primary beneficiary whose relationship is ______________________________ and will be entitled to my death benefits and F.O.P. insurance.

I hereby appoint ________________________________, address______________________________ as my secondary beneficiary whose relationship is ______________________________ .

Understanding that these benefits will be paid upon legal notification to the Lodge Secretary of my death. Initial here:________.

I hereby swear that the above information is true and accurate to the best of my knowledge and that I am a full time law enforcement officer or I have left law enforcement in good standing.  I also authorize the Fraternal Order of Police to contact my employer or prior employer to verify my present or past employment, and to do a criminal history check.

Applicant Signature:_____________________________________    Witness:_____________________________________

It is the responsibility of each member to keep this form current by reporting changes to the Lodge Secretary in writing.

Remarks/Changes:_________________________________________________________________________.

Dues: $45.00 per year. Submit with completed application.

Date Application Received: ___________________. Date Reviewed::_________________. By: __________________________

Status of Application: Approved: ____________   Rejected: ____________     Other: ___________________________________.
 
Date sworn in to Lodge:___________________.

This form must accompany your dues.

        
Mail to:  FOP Lodge 113
                P.O. Box 3
                Harrison, OH 45030