Palm Beach County FOP Lodge 50

APPLICATION FOR MEMBERSHIP

Please Note: Do not provide your government or agency email address as all content is subject to FSS Chapter 119. Failure to do so will delay the application process.

Application for Membership

PART I - PERSONAL INFORMATION

Last Name *

First Name *

Middle Initial

Suffix

Street Number & Name *

Apt/Suite

City *

State *

Zip Code *

Cell Phone *

Personal E-Mail Address *

Agency Name *

Employee ID or Badge Number *

Date of Hire or Retirement *

Former FOP Member? *

Lodge Number and State

How Did You Hear About Us? *

If referred by an FOP member, who may we thank?

PART II - CHOOSE MEMBERSHIP TYPE & PAYMENT

Note: Monthly automatic dues deduction is an available option only to members enrolled in the Lodge Legal Aid Program. ALL members may pay annually by credit/debit card, Zelle, or by check. Refer to Payment Options below.

Active Member with Legal Aid - $540.00/year

Monthly ACH Automatic Dues Deduction ($45/month) - Must Complete Part III

Active Member with Legal Aid - $540.00/year

Other - See Payment Options Below

Active Member w/o Legal Aid - $65.00/year

Annual Only - See Payment Options Below

Associate Member - $540.00/year

Monthly ACH Automatic Dues Deduction ($45/month)- Must Complete Part III

Associate Member - $540.00/year

Other - See Payment Options Below

OTHER PAYMENT OPTIONS

OPTION 1 - CLICK TO PAY BY CREDIT OR DEBIT
OPTION 2- BY ZELLE FROM YOUR BANKING APP - SEND PAYMENT TO: treasurer@foplodge50.org
OPTION 3 - BY CHECK PAYABLE TO: FOP Lodge 50, PO Box 13044, North Palm Beach, FL 33408

PART III - AUTOMATIC DUES DEDUCTION AUTHORIZATION

Complete Only If Deducting Dues From Checking Account

Name on Account

Bank Name

Account Number

Routing Number

Authorization

By typing my name and date, I hereby authorize FOP Lodge 50 to initiate monthly debit entries in the amount of $45.00 (or more in the event of a dues increase) from my checking account for my membership dues which includes Legal Aid. This authorization is to remain in full force and effect until FOP Lodge 50 has received written notification from me to terminate the ACH debit. This termination notification will be provided in a timely manner as to afford FOP Lodge 50 and my bank the reasonable opportunity to act to avoid any penalty for non-payment. I agree to immediately notify FOP Lodge 50 with changes in my bank account. I understand that any non-payment will result in suspension of member privileges and legal aid protection until all delinquent dues and penalty fees are paid.

Full Name

PART IV - MEMBERSHIP OATH

CLICK TO REVIEW

I Have Read and Agree *

Agree

PART V - APPLICANT CERTIFICATION

I understand that I am voluntarily submitting this petition for membership and it is my responsibility to notify FOP Lodge 50 of any changes to my address, phone numbers, email or other contact information. I further understand and agree that it is my responsibility to notify FOP Lodge 50 of any changes regarding my employment status if actively employed as a sworn officer or corrections officer.

By typing my name and date below, I certify the above information contained in this application to be true and correct to the best of my knowledge, and that this information can be used for the purpose of processing my application for membership. I understand that to falsify information is grounds for my application and/or membership to be denied. I authorize any person, organization or company listed on this application to furnish you and all information concerning my current or previous employment and qualifications for membership.

Full Name *

Date *

* Required Fields