| Western Hamilton County, Ohio F.O.P. Lodge # 84 |
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.
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: $40.00 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: Patti Brown, Secretary; 6323 Glengariff, Cincinnati, Ohio 45230
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: $40.00 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: Patti Brown, Secretary; 6323 Glengariff, Cincinnati, Ohio 45230
