Jim Fogleman Lodge 50, Inc.

FRATERNAL ORDER OF POLICE

Jim Fogleman Lodge #50, Inc

P.O. Box 13044

North Palm Beach, Florida 33408

Office: 561-899-5050 Email: info@foplodge50.org

www.foplodge50.org

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APPLICATION FOR MEMBERSHIP

ACTIVE MEMBER - The applicant must be a full-time or retired sworn law enforcement or corrections officer and not have been convicted of a felony offense. An applicant cannot be an active member of more than one FOP Lodge per National FOP By-Laws.

ASSOCIATE MEMBER - Reserve deputy, part-time officer or non-sworn employee of a government entity seeking legal aid. The applicant must not have been convicted of a felony offense. Associate memberships are predicated by the associate member’s employment with a government entity, law enforcement, corrections, or public safety agency. When an associate member’s employment is terminated, their affiliation with Jim Fogelman Lodge 50 Inc ends as well. It is the associate member’s duty to notify the Lodge of any change in employment status.

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.

Please have the following ready to be entered or uploaded prior to completing the application:

a copy of your government or agency's active or retirement credentials (if applicable), in .jpg/.png or similar image file format (Mandatory)
current checking account number and bank routing number if choosing to pay by Automatic Monthly Dues Deduction or
a copy of a voided check from your current checking account, in .jpg/.png or similar image file format (Optional)

Application for Membership

PART I - PERSONAL INFORMATION

Last Name *

First Name *

Middle Initial

Suffix

Date of Birth *

Street Number & Name *

Apt/Suite

City *

State *

Zip Code *

Home Phone *

Cell Phone *

Personal E-Mail Address *

Agency Name *

Title or Rank *

Employee ID or Badge Number *

Division *

Date of Hire or Retirement *

Agency or Government ID *

A copy of your agency ID (Active or Retired) must be submitted with application

Former FOP Member? *

Lodge Number and State

PART II - MEMBERSHIP DUES & PAYMENT OPTIONS

Dues *

Payment Options *

PART III - AUTOMATIC DUES DEDUCTION AUTHORIZATION

Complete Only If Deducting Dues From Checking Account

Name on Account

Bank Name

Account Number

Routing Number

Copy of Voided Check (Optional)

Authorization

By typing my name and date, I hereby authorize FOP Lodge 50 to initiate monthly debit entries in the amount of $35.00 (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

Date

PART IV - MEMBERSHIP OATH

As an active or associate member of the Fraternal Order of Police, Jim Fogleman Lodge #50 Inc, I do most solemnly and sincerely promise and swear by typing my name and date below, that I will to the best of my ability comply with all the rules of this order; that I will recognize the authority of my legally elected officers and obey all orders there from 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 the 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 or obligation, I hereby consent to be expelled from the Order.

Full Name *

Date *

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 *