Lodge #4 • FOP Lodge 4

Active / Retired Membership Application

Member Information

Date

First Name *

M.I.

Last Name *

Phone *

Email *

Birthdate *

Street Address *

Street Address Line 2

City *

State *

Zip *

Have you been a member of this lodge before?

Previous Membership Number

Are you a member of another lodge?

State

Lodge Number

Are you retired?

Retired Agency

Employer

Position

The State Lodge-sponsored Accidental Death & Disability policy is not valid without an identified beneficiary and member signature.

Beneficiary *

Relationship *

SSN (Last 4) * Encrypted at rest. Only the last 4 digits.

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