Fraternal Order of Police Associate Membership Application

	Fraternal Order of Police Volusia County Jim White Lodge #40 P.O. Box 943 New Smyrna Beach, FL 32170-0943

Telephone (386) 423-2325	PETITION FOR ASSOCIATE MEMBERSHIP AND INITIATION PLEASE PRINT OR TYPE	Fax (386) 423-1554

APPLICANT'S NAME _____________________________________________________________ This organization is formed for the purpose of increasing the understanding of the rights, duties, and problems of police officers; of fostering public respect for police officers; of strengthening the comradeship; of bettering the conditions under which they serve society; of promoting their interests and welfare in every conceivable way; and of being ever ready to render any lawful assistance, as may be required, to the Florida State Lodge, Fraternal Order of Police, or any of its subordinate Lodges and members.

Home Address_________________________________________________________________________

City_____________________________________________ State___________ ZIP+4 Code___________

Mailing Address_______________________________________________________________________

City_____________________________________________ State___________ ZIP+4 Code___________

Occupation_______________________________ Name of Firm_______________________________

U.S. Citizen: Yes(__) No(__) If No, give country of birth:____________________________________

Date of Birth_________________ Work Phone (___) ____________ Home Phone (___) ___________

SSN: ________-________-________ Important - Your E-Maill Address__________________________
Have you ever pleaded guilty to, or been convicted of, a crime not including traffic violations? Yes_____ No_____ If yes, give details:(Continue on reverse side if necessary) ___________________________________________________________________________________________
Are you now, or have you ever been, a member directly or indirectly connected or affiliated with any organization or group advocating or believing in the overthrow of the government of the United States by force?_________________ Are you willing to assume an obligation that will not conflict with your duties to yourself, or your family, or your religous or political opinions; and that will bind you to uphold the constitution and laws of the United States of America? ________

I agree, if found qualified, to abide by all the laws, rules, and regulations of the Order; and I acknowledge that all decals, membership card, emblems, etc., are the property of the Lodge and may be recalled by this Lodge or any Lodge of this Order for misuse, or for non-payment of dues. I further agree to return said items within 10 days of an official request. I further understand and agree my failure to comply will subject me to arrest under Florida Statute 817.311. I hereby affirm and certify all the above answers and statements are true and factual to the best of my knowledge and belief. I pledge to abide by all the laws, rules, and regulations of this order.

Applicant's Signature_________________________________________ Date____________________

Lodge Use Only: Sponsoring member(s) _________________________________________________
Approved _________________________ Meeting Date _______________ Initiation Date _____________

Lodge Computer ________ E-Mail List ____________ Make Dues Check of $50.00 payable to: FOPA Lodge #40. Your check will be returned if your application is not approved.

Lodge Location: 471 Old Mission Road, New Smyrna Beach, FL