Monmouth County Fraternal Order Of Police

Lodge 73

Associate Membership Application

Applicants Name:__________________________________________ Home Phone No:(______)_______-______________

Present Home Address:___________________________________ City ____________________ State ____ Zip ________

Previous Home Address:___________________________________City____________________ State_____ Zip________

(If present address is less than five (5) years)

Social Security Number:___________/_________/___________ Date of Birth: ____________________________________

Drivers License Number:______________________________________ State:_________________________

Email address______________________ Employer Phone Number (_____)_______-_____________________

Present Occupation:_______________________ Employer Name & Address:_____________________________________

PLEASE CHECK ONE: Married:______ Single: ______ Divorced: ______ Widowed: ______

Spouse's Name: _______________________________________ Spouse's Date of Birth: ___________________________

Children's Names & Ages: _____________________________________________________________________________

HAVE YOU EVER BEEN DENIED ASSOCIATE MEMBERSHIP IN ANY  F.O.P. LODGE    YES:___ NO:___

ARE YOU NOW , OR HAVE YOU EVER BEEN A MEMBER OF ANY ORGANIZATION THAT ADVOCATED THE OVERTHROW OF OUR GOVERNMENT? Yes:___ No:___.  HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE: Yes:___ No:__           REFERENCES: (List the names and addresses and telephone numbers of two (2) people who have known you for at least five years:

Name: _____________________________ Address: ____________________________________ Phone: _____________

Name: _____________________________ Address: ____________________________________ Phone: _____________

PLEASE READ: UNDER THE TERMS AND GUIDELINES SET FORTH AND EXPLAINED TO ME, I HEREBY APPLY FOR ASSOCIATE MEMBERSHIP WITH F.O.P. LODGE 73 I CONSENT AND GIVE FREELY ANY INFORMATION REQUESTED OF ME WITH THE UNDERSTANDING THAT SUCH INFORMATION REQUESTED OF ME WITH THE UNDERSTANDING THAT SUCH INFORMATION WILL BE USED SOLELY FOR THE PURPOSE INTENDED, AND SHALL REMAIN CONFIDENTIAL IN NATURE. I FURTHER  AGREE TO SAFELY KEEP IN MY POSSESSION ALL ARTICLES ISSUED TO ME BY THIS ASSOCIATION, AND WILL RETURN ANY AND ALL ARTICLES TO SAID ASSOCIATION UPON DEMAND. (EVERY QUESTION MUST BE ANSWERED)

Applicants Signature: ________________________________________________    Date: __________________________

NOTE: This Association reserves the right to deny any applicant for Associate Membership without justification of it's action.

APPROVED: ________ DENIED: _________        Date: _______________________

President/Vice President ______________________ Chairperson of Associated Committee ____________________________

                                                                                                                                                   Ralph A. Striano                          

MAIL COMPLETED FORM WITH CHECK FOR $110.00 + $8.00 S&H = $118.00 (you can add $10.00 for a plastic shield holder) for a total of $128.00

TO F.O.P. LODGE 73, P.O. Box 1134, Freehold, New Jersey 07728