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Stone City Lodge #94 Fraternal Order of Police
Active $36 (Police Only)  /  Associate $25
Member Application

Name: ___________________________________________________________________


Age: _____      Date of Birth: ____/____/____    Phone Number:  (_____) _____-_______

Occupation: _______________________________________________________________

How long have you been a resident of Lawrence County? __________________________

List any arrests, including Traffic Citations: _____________________________________


Date of Application: _____/_____/_____

This is to certify that I have completed the above application and that the above information is true and correct to the best of my knowledge.  I agree to abide by the Constitution and By-Laws of the Stone City Lodge F.O.P. #94 and should my membership be revoked, I shall return to the Secretary the emblems and membership card that was furnished to me by the lodge.

Applicant's Signature: ______________________________________________________

Recommended by: _________________________________________________________

Note: Any application that is not filled out completely and in detail by the applicant
cannot be accepted for proposal by the lodge.

Please make checks payable to Stone City Lodge #94 F.O.P. and mail your application form to:

Stone City Lodge #94 F.O.P.
P.O. Box 52
Bedford, IN 47421

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