Membership Application

CHARLOTTE-MECKLENBURG LODGE NO.9
Membership Application 2020

First Name: Middle Initial: Last Name: Sr, Jr, III:

Date of Birth Month: Day: Year: Sex: Personal Email: Last 4 SS#

Home Address: City: State: Zip Code:

Home Phone: Work Phone: Cell Phone:

Division: Employer: Email:

Work Address: City: State: Zip Code:

Beneficiary: Relationship: Address:

City: State:

Zip Code: Phone:

PLEASE CHECK THE APPROPRIATE ITEM

Active New........$199.00 Active Renewal.....$199.00 Active Retirees....$100.00
Affiliate (Reserve & Detention Offices, Support Personel).......$199.00 Associate...........$75.00

Payroll Deduction Pay Pal Cash Check

Membership dues are due on August 1st of each year and after October 1st your benefits will stop and a $10.00 administrative fee will be applied.

Don't let yourself become uncovered and have something happen where you or your family will need one or all of the benefits.
The revenue act 1987 requires us to reminds you that dues are not tax deductible

Completing the this form by entering your full name in both areas and entering date, constitutes you agree to all terms of membership in the Fraternal Order of Police

Obligation I, , in the presence of the Creator of the Universe and the members of the Fraternal Order of Police here assembled, do most solemnly and sincerely promise and swear, that I will, to the best of my ability comply with all the laws and rules of this Order; that I will recognize the authority of my legally elected officers and obey all orders therefrom not in conflict with my religious or political views, or my rights as an American citizen; that I will not cheat, wrong, or defraud this Order, or any member there of, or permit the same to be done if in my power to prevent it; that I will at all times aid and assist a worthy Brother (or Sister) in sickness or distress, so far as it lies in my power to do so that I will not divulge any of the secrets of this Order to any one not entitles to receive them. To all of which I most solemnly and sincerely promise and swear. Should I violate this, my solemn oath or obligation, I hereby consent to be expelled from the Order.

Signature Date

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CHARLOTTE-MECKLENBURG LODGE NO.9Membership Application 2020

CHARLOTTE-MECKLENBURG LODGE NO.9
Membership Application 2020