Western Hamilton County, Ohio F.O.P. Lodge # 84
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I hereby make application to become a member of Western Hamilton County, Ohio F.O.P. Lodge # 84. I affirm that I am a full time Law
Enforcement Officer in the State of Ohio. I certify that I am not a member of any Organization competing for membership with the
Fraternal Order of Police.
Name:__________________________________________________________________
Address:________________________________________________________________
City:____________________ State:_________ Zip:_________
Home Phone:__________________________
Department:_______________________________________________________________
Work Phone:__________________________ E-Mail:______________________________
Number of Children:______
Children(s) Name(s): Date of Birth
_______________________________ _____________
_______________________________ _____________
_______________________________ _____________
_______________________________ _____________
(If more room is needed, use the back of this form)
I hereby appoint ________________________, address_____________________________ as my primary
beneficiary whose relationship is_________________________ and will be entitled to my death benefits and F.O.P.
insurance.
I hereby appoint ________________________, address_____________________________ as my secondary
beneficiary whose relationship is_________________________. Understanding that these benefits will be paid upon
legal notification to the Lodge Secretary of my death. Initial here:________.
Signature:___________________________________ Witness:____________________________________
It is the responsibility of each member to keep this form current by reporting changes to the Lodge Secretary in
writing.
Remarks/Changes:__________________________________________________________________.
Meetings: The Lodge meets every Third Tuesday of every month at Harvest Home Park Lodge at 7:30 P.M.
Dues: for Active Officers are $50.00 per year + a $5.00 one time Initiation Fee.
Submit with completed application.
Date Dues Paid:_________________. Date Application Accepted___________________.
Date sworn in to Lodge:___________________.
This form must accompany your dues.
Mail to: Bob Uhl, Treasurer c/o Cheviot PD, 3814 Harrison Ave, Cheviot, OH 45211