New York State Fraternal Order of Police
Suffolk County Lodge #124
PO Box 787, Smithtown, NY 11787
2013 Membership Application
Check One: Active Member - New ($50.00) Associate Member - New ($60.00)
Active Member - Renewal ($50.00) Associate Member - Renewal ($60.00)
All Applicants Complete The Following
First Last Date
Name: ____________________ MI: ____ Name: ___________________________ of Birth: ____________
Address: ______________________________________________________________ Apt.: _______________
City: _______________________________ State: ____________________________ ZIP: _______________
Phone 1: ____________________________ Phone 2: _________________________
E-Mail Address: ________________________________________________________
Beneficiary (Full Name): _________________________________ Relationship To You: _________________
Law Enforcement Officers - Active Membership Qualifications
Active membership in the New York State Fraternal Order of Police Suffolk County Lodge #124 is open to any regularly
appointed or elected full-time, or retired, sworn law enforcement officer with arrest powers who is employed by the United
States, or a state, city, town, village or political sub-division therein and subject to its Constitution and By-Laws.
I HEREBY DECLARE THAT I AM A FULL-TIME OR RETIRED FULL-TIME LAW ENFORCEMENT OFFICER WITH ARREST POWERS
EMPLOYED BY THE UNITED STATES, OR A STATE, CITY, TOWN, VILLAGE OR POLITICAL SUB-DIVISION THEREIN.
Applicant Signature: ________________________________________________ Date: ________________
Dept./Agency: ____________________________________ Command/Unit: ________________________
Rank/Title: ______________________________________ Active/Retired: ________________________
A photocopy of your law enforcement ID Card (active or retired) is required when applying as a New Member!
If accepted for membership, I understand that all FOP materials, including ID cards, decals and any other materials
indicating membership in this organization remain the property of the FOP and must be returned upon demand.
Check or Money Order Payable To: FOP Suffolk Lodge 124
PO Box 787
Smithtown, NY 11787
For Office Use Only
Received: __________________ Check #: ____________ Amount: ____________ Employment Verification: __________________
Accepted: __________________ Denied: ____________ Reason: _____________________________________________________