Fraternal Order of Police NYS Lodge 17

Associate Application
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Print Application, enclose check for $40 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 ASSOCIATE MEMBERSHIP APPLICATION

(NEW AND RENEWAL)

Dues $40.00

NAME:_____________________________D.O.B.:___________SS#_______________

ADDRESS:_____________________________________________________________

CITY& STATE:________________________________________________ZIP:_____________

HOME PHONE:_____________________________EMAIL:____________________________

BUSINESS:__________________________________PHONE____________________

JOB TITLE:_________________________________________________________________

[  ] NEW MEMBER [  ] RENEWAL (CHECK ONE)

I hereby promise to support Law Enforcement and Lodge # 17 of the New York State Fraternal Order of Police as well as the laws and constitutions of New York and the United States of America. In addition, I have never been convicted of a felony.

 

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Signature Date

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