FOP Lodge #29 Membership Application Form

Fraternal Order of Police Laurens County Lodge #29, Inc. Membership Application

To apply for membership please complete all questions.
Name*

First NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Non Work E-mail*
Cellular Number*

Area CodePhone Number
Work Number*

Area CodePhone Number
Last 4 digits of Social Security Number*
Demographics*

Age:DOB:Gender
Membership Type
prevnext( X )
1 Year Active Membership$100.00

1 Year Retired Membership$50.00
Retired

1 Year Associate Membership$30.00
Employer (Even if Retired, list last agency you served with).*

AgencyTitleHow Long There?
For the Life Insurance please provide the following information. Life Insurance is NO cost to Active members that meet qualifications. NOT available to Associate members.
Life Insurance*

Beneficiary DOBRelationship
Do you have any dependent children?*

YESNO
If (YES) please list names and ages.

First NameLast NameAge
Child # 2

First NameLast NameAge
Child # 3

First NameLast NameAge
Child # 4

First NameLast NameAge
I DO MOST SOLEMNLY AND SINCERLEY PROMISE AND SWEAR, THAT I WILL TO THE BEST OF MY ABILITY COMPLY WITH ALL OF THE LAWS AND RULES OF THIS ORDER; THAT I WILL RECOGNIZE THE AURTHORITY OF MY LEGALLY ELECTED OFFICERS AND OBEY ALL ORDERS THERE FROM NOT IN CONFLICT WITH MY RELIGIOUS OR POLITICAL VIEWS, OR MY RIGHT AS AN AMERICAN CITIZEN; THAT I WILL NOT CHEAT, WRONG, OR DEFRUAD THIS ORDER, OR ANY MEMBER THEREOF, OR PERMIT THE SAME TO BE DONE IF IN MY POWER TO PREVENT IT; THAT I WILL IN ALL TIMES AID AND ASSIST A WORTHY BROTHER OR SISTER IN SICKNESS OR DISTRESS SO FAR AS IT LIES IN MY POWER TO DO SO; THAT I WILL NOT DIVULGE ANY SECRETS OF THIS ORDER TO ANYONE NOT ENTITLED TO RECEIVE THEM. TO ALL OF WHICH I MOST SOLEMNLY AND SINCERELY PROMISE AND SWEAR. SHOULD I VIOLATE THIS , MY SLOEMN OATH AND OBLIAGTION, I HEREBY CONSENT TO BE EXPELLED FROM THIS ORDER.
Signature*

Clear
Date*

MonthDayYear
Date of Application and signature
By submitting your E-signature, you state that all information is true and accurate to the best of your knowledge.

** We DO reserve the right to refuse membership to anyone; however, we do not and will not discriminate on the basis of nationality, race, religion, gender, sexual orientation, disability, or any other protected class or designation.
Payment options:
- Cashapp - $laurensfopsc29 (Preferred payment method)
- Venmo - @Laurensfopsc29
- Check or Cash (Given to President Chris Hudson)
Should be Empty:

Fraternal Order of Police Laurens County Lodge #29, Inc. Membership Application