Monmouth County Fraternal Order Of Police

Lodge 73

Membership Application

Name: ______________________________________________________ D.O.B.___________________

Home Address: ________________________________________________________________________

City: _____________________________________ State: ______________ Zip:____________________

Telephone: (_______)_________-__________________ S.S.#___________/_________/_____________

E-Mail Address: ________________________________________________________________________

Branch of Law Enforcement: ______________________________________________________________

Title or Rank: __________________________________ F.O.P. Car Shield # ________________________

Name & Rank of Supervisor for employment verification: ________________________________________

Work Phone #:(_______)_________-_______________ D.L.#___________-____________-____________

I, ____________________________________________ hereby request membership in the Fraternal Order of Police, Lodge 73. I understand that ALL applicants must be a recognized law enforcement officer or supervisor and that the above stated facts are true. I fully understand that any falsification of these facts is grounds for my termination from this lodge.

Initial Fee: $95.00 by check or M.O. must accompany this application. If for any reason admission to this lodge is denied, this fee will be returned.

BASIC MEMBERSHIP: $20.00 a month__________________________         _______________ 

                                                                                                            Signature for acceptance                                                Date of acceptance

(Entitled to full membership in the Fraternal Order of Police, EXCLUDING LEGAL DEFENSE and life insurance offered by lodge #73).  Note: Legal defense may be obtained through A.J. Fusco's office privately.)

FULL MEMBERSHIP:   $36.00 a month __________________________         _______________ 

                                                                                                            Signature for acceptance                                                Date of acceptance

(Entitled to full membership in the Fraternal Order of Police, INCLUDING LEGAL DEFENSE and life insurance offered by lodge #73)

RETIRED MEMBERSHIP: $75.00 a year __________________________        ______________

                                                                                                            Signature for acceptance                                                Date of acceptance

(Entitled to full Membership in the Fraternal Order of Police including Lodge life insurance, BUT EXCLUDING ANY LEGAL DEFENSE)

Mail this completed form with your check to: Monmouth County Fraternal Order Of Police Lodge 73, Attention Membership Committee, P.O. Box 1134, Freehold, New Jersey 07728

        Signature of Sponsor: _________________________________ Date: _______________

        Signature of Secretary: ________________________________ Date: _______________

                              APPROVED: ___________                                     DENIED: ____________