NYSFOP BIG APPLE LODGE #102

NEW YORK STATE
FRATERNAL ORDER OF POLICE
BIG APPLE LODGE #102
20-25 45TH STREET
ASTORIA, NEW YORK 11IO5
(718) 956-0233
E-MAIL: FOP102NY@AOL.COM
APPLICATION FOR MEMBERSHIP

Last Name:___________________ First:______________ Init:_____
Street Address________________________________ Apt#_____
City:____________________ State:______ Zip:_______________
Tele #:____________ E-mail:______________________________
DOB:___________________
Date Of Appointment:____________
Dept/Agency__________________ Rank/Position______________
Office Tele # _______________________
Cell Tele #:_____________

FOR ACTIVE AND ACTIVE/RETIRED MEMBERS:
ATTACH A COPY OF YOUR DEPT. ID CARD (MANDATORY)
Members Beneficiary: (must be filled in)
Name:__________________________Relationship______________
Address:________________________City:____________________
State:____ Zip:_________
Tele #_____________________________
Members Signature:______________________________________

Sponsored By: ___________________________________________
Check One: ACTIVE ( ) ACTIVE/RETIRED ( ) ASSOCIATE ( )
Check One: NEW ( ) RENEWAL ( )
DUES $40 YEAR (DUES ARE DUE IN OCTOBER EACH YEAR)
MAKE CHECKS OUT TO: FRATERNAL ORDER OF POLICE AT
THE ABOVE ADDRESS.