Fraternal Order of Police NYS Lodge 17
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Print Application, enclose check for $35 made out to "Fraternal Order of Police Lodge 17" and mail to:
  
 Fraternal Order of Police Lodge #17
United Law Enforcement Officers
PO Box 656764
Flushing, New York  11365-6764

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 2010 MEMBERSHIP APPLICATION

(NEW AND RENEWAL)

 Dues $35.00

NAME:___________________________

D.O.B.:___________SS#_________________

ADDRESS:_____________________________________________________________

CITY_____________________STATE:_________________ZIP:_____________

HOME PHONE:_________________________EMAIL:________________________

DEPT/AGENCY: _____________________________________________________

RANK/TITLE: __________________________COMMAND______________

[  ] NEW MEMBER [  ] RENEWAL (CHECK ONE)

New Member (Sponsor required or submit proof that you meet requirements for membership)

Sponsor's Name___________________

Command ______________Member #_____________

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