Membership Application

Membership Application

www.scfop.org
Name *

First Name Middle Name Last Name
Agency Name *
Name the agency (leave off "City/Town/County of), PD or SO is ok.
Application Date *

Month Day Year
Date
Home Address *

Street Address

COUNTY you reside

City State

Zip Code
Work Address *

Street Address

COUNTY (not country)

City State

Zip Code
Personal E-mail Address *
example@example.com
Phone Number *
Please enter a valid phone number.
Birthdate *
Sex *
Service Classification *
Adding Legal Defense? *
Additional Information will be supplied
Preferred Form of Contact *
Oath Acceptance / Terms and Conditions *
Membership Committee Use Only

Applicant Sponsor: __________________________ Dues Paid? _____ How Paid? _______

Tentative Approval Granted for legal defense: YES / NO Final Lodge Approval: YES / NO

Date of Vote: ___________________ Dues Paid? YES / NO How Paid? _____________

Lodge President's Signature:__________________________________________
Should be Empty: