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FRATERNAL ORDER OF POLICE
Arizona Lodge 44 for Corrections
Membership Application
Using Bank ACH withdrawal
NAME:
*
Full Legal Name
MAILING ADDRESS:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CELL PHONE:
*
Format: (000) 000-0000.
DATE OF BIRTH:
*
-
Month
-
Day
Year
For Member AD&D Insurance Policy
GENDER:
*
MALE
FEMALE
NON-WORK EMAIL:
*
example@example.com
WORK LOCATION:
*
Eyman, Lewis, Phoenix...
UNIT:
*
Unit you work at
RANK:
*
DATE OF HIRE:
*
-
Month
-
Day
Year
Date
EIN:
*
Employee Identification Number
TAKE A PHOTO OF YOUR DEPARTMENT ID...
...OR UPLOAD DEPARTMENT ID FROM PHONE PHOTOS OR COMPUTER
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FOR FASTER PROCESSING OF YOUR APPLICATION, PLEASE TAKE A PHOTO OF YOUR DEPARTMENT ID, RETIRED ID, OR ARIZONA DRIVER'S LICENSE ABOVE, OR UPLOAD IT FROM YOUR PHONE/COMPUTER HERE
Cancel
of
ARE YOU CURRENTLY UNDER INVESTIGATION?
*
NO
YES
WHAT TYPE OF INVESTIGATION IS IT?
ON DUTY ADMINISTRATIVE (AI)
ON DUTY CRIMINAL (CIU INVOLVEMENT)
OFF DUTY ADMINISTRATIVE (AI)
OFF DUTY CRIMINAL (POLICE INVOLVEMENT)
OFF DUTY TRAFFIC TICKET
OFF DUTY CRIMINAL TRAFFIC TICKET
EEO
DID YOU ALREADY RECEIVE AN (AI) 601 FORM?
YES
NO
UPLOAD (AI) 601 COMPLAINT
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of
PHONE:
*
Format: (000) 000-0000.
This is an application for the Fraternal Order of Police, Lodge 44 Membership. Fraternal Order of Police, Lodge 44 Dues are $17.00 per pay period ($34 per month) which includes our legal plan. If you chose PAYROLL DEDUCT, your membership will not start until your PAYROLL DEDUCT is turned in to your Personal Office and payment is received by the Arizona Legal Council. In signing this application you also attest to the following:
I hereby apply for membership in the Fraternal Order of Police/Arizona Labor Council, Inc. (FOP/ALC). I authorize the FOP/ALC to act as my official representative in job related matters concerning my wages, hours, and conditions of employment in order to promote and protect my economic welfare.
Further, I do solemnly and sincerely promise and swear, that I will, to the best of my ability, comply with all the laws and rules of this Order; that I will recognize the authority of my legal elected officers and obey all orders therefrom not in conflict with my religious or political views, or my rights as an American citizen; that I will not cheat, wrong, or defraud this Order, or any member thereof, or permit the same to be done if in my power to prevent it; that I will, at 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 of the 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 solemn oath of obligation, I hereby consent to be expelled from the Order. This application for FOP membership will not become effective until approved by the FOP Lodge 44 Membership. Legal coverage will be effective when payment is received by FOP/ALC via payroll deduction. (normally 30 days after turning into payroll liaison)
SIGNATURE:
*
DATE:
*
-
Month
-
Day
Year
Date
DO YOU NEED TO DROP OTHER UNIONS?
APA/ACA
AZCPOA
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AUTHORIZATION AGREEMENT FOR DIRECT PAYMENT (ACH DEBITS)
COMPANY NAME: THE FRATERNAL ORDER OF POLICE, ARIZONA LABOR COUNCIL, INC.
I (we) hereby authorize THE FRATERNAL ORDER OF POLICE, ARIZONA LABOR COUNCIL, INC. (hereinafter "FOP/ALC") to initiate debit entries to my (our) Checking account indicated below at the financial institution (hereinafter "DEPOSITORY") named below, to debit the same of an amount not to exceed
$34.00 per month, ($20.00 ALC dues and $14.00 to Lodge 44)
to such account on or between the 25
th
to the 28
th
of each month. Transactions will begin the month following the date of this authorization.
MY DEPOSITORY NAME: (bank, credit union, etc.)
*
This authorization is to remain in full force and effect until the FOP/ALC has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the FOP/ALC and my (our) DEPOSITORY a reasonable opportunity to act on it.
NAME:
*
DATE:
*
-
Month
-
Day
Year
Today's Date
SIGNATURE:
*
PLEASE WRITE THE BANK ROUTING NUMBER AND ACCOUT NUMBER BELOW:
ROUTING NUMBER:
*
ACCOUNT NUMBER:
*
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