FOP Lodge 4
Lodge #4
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Lodge #4 • FOP Lodge 4
Active / Retired Membership Application
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Member Information
Date
First Name
*
M.I.
Last Name
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Phone
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Email
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Birthdate
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Address
Street Address
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Street Address Line 2
City
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State
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Membership Details
Have you been a member of this lodge before?
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Previous Membership Number
Are you a member of another lodge?
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State
Lodge Number
Are you retired?
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Retired Agency
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Position
Beneficiary
The State Lodge-sponsored Accidental Death & Disability policy is
not valid
without an identified beneficiary and member signature.
Beneficiary
*
Relationship
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SSN (Last 4)
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Encrypted at rest. Only the last 4 digits.
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