New Active Member Application

$55.00

IDENTIFICATION
Name*
First Middle Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Driver License Number*
State of Issue:*
State / Province / Region
Current Address*
Mailing Address Physical Address City State ZIP Code
Email
Enter Email Confirm Email

A valid email address is needed to have an account on your F.O.P. Lodge #3 Website.
Phone
Date
Date Format: MM slash DD slash YYYY
EMPLOYMENT
Employer*
Title*
ACKNOWLEDGEMENT
Qualifying Agency*
Have you ever been convicted of a felony?*
- No
- Yes
First Proposer*
Provide First & Last Name
Second Proposer*
Provide First & Last Name
I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE AND CORRECT. I UNDERSTAND THAT MEMBERSHIP IS SUBJECT TO A BACKGROUND INVESTIGATION AND FINAL MEMBERSHIP APPROVAL IS BY FINAL DECISION OF THE BOARD OF DIRECTORS.
I ALSO UNDERSTAND THAT MEMBERSHIP APPLICATION FEES ARE NON-REFUNDABLE.
Signature*
Use a touch device or mouse to sign.
Signing Date*
Date Format: MM slash DD slash YYYY

IDENTIFICATION