Membership Application

Membership Application

www.scfop.org
Name*

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

MonthDayYear
Date
Home Address*

Street Address

COUNTY you reside

CityState

Zip Code
Work Address*

Street Address

COUNTY (not country)

CityState

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: