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.

NAME: _________________________________________________________________________________        

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
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