Honorary Membership Application
I hereby make application to become an Honorary Member of Western Hamilton County F.O.P. Lodge #84.
I affirm that I am an individual presently assisting or serving in an organization attached to a Law Enforcement
Agency that is designed or intended to further the image or assist the said Agency in the furtherance of the image
of Law Enforcement or to aid the said Agency in the performance of their sworn duty. I certify that I've been
bestowed the rank of Special Deputy and/or the Rank or commission of a Police Officer in the State of Ohio.
ADDRESS:_______________________________ CITY:_______________ STATE: ______ ZIP:___________
HOME PHONE:___________________________ WORK PHONE:____________________________________
DEPARTMENT OR ORGANIZATION:________________________________ RANK:_____________________
NUMBER OF CHILDREN:___________
CHILDREN(S) NAME(S) : DATE OF BIRTH:
(IF MORE ROOM IS NEEDED USE THE BACK OF THIS FORM)
I hereby acknowledge that my membership within F.O.P. Lodge #84 is an Honorary Membership and I have no
voting rights. Initial Here: ____________
I also agree that my Membership as an Honorary Member is subject to cancellation at any time if I leave the
organization that I was a member of when I solicited for Honorary Membership into Lodge #84.
Initial Here: _________
Signature:____________________________ Date: _____________ Witness:_________________________
It is the responsibility of each Honorary Member to keep this form current by reporting changes to the Lodge
Secretary in writing.
Meetings: The Lodge meets every Third Tuesday at Harvest Home Park Lodge at 7:30 P.M.
Dues: $25.00 per year + $5.00 one time Initiation fee.
Names of the Three (3) referring members who are active and in good standing with FOP 84
1) _________________________ 2) _________________________ 3) _________________________
Date Dues Paid: _________ Date App. Accepted:_________Date Sworn into the Lodge:__________
Sworn in by:_______________________________________________________
This form must accompany your dues.
Mail To: FOP 84, 104 Kings Rd Milford, Ohio 45150
revised 2/28/12 pb This form supersedes all previous editions, earlier editions should not be used