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When complete, print it out and send it with your dues to:

Fraternal Order of Police
5 Rita Crescent
Commack, N.Y. 11725

	FRATERNAL ORDER OF POLICE NYC HOUSING POLICE SILVER AND GOLD LODGE #997
Last Name:     First Name:     M.I.
Address :   Home Phone: ()-
City :   State :      Zip Code:
Email Address :       D/O/B://
Rank : Agency : Command :
Current Status - Active/Retired :
Member Beneficiary (Applicants age 63 and older are ineligible for survivor benefits):      Member Signature : ___________________________  Date : ____/____/____
New Active Members $40.00                   Date Received : New Associate Member $45.00

An FOP Active Member includes all active & retired Law Enforcement.
NOTICE: Prospective active members MUST attach a copy of their law enforcement ID card.
An FOP Associate Member includes all NON-Law Enforcement.
Please submit dues based on your own correct designation.