APPLICATION FOR MEMBERSHIP

To the officers of the Fraternal Order of Police:

I, the undersigned, a full-time, regularly employed law enforcement officer, do hereby make application for Active Membership in the El Paso Federal Officer’s Regional Lodge #82. I furthermore do / do not (circle one) wish to participate in the Legal Defense Plan sanctioned by the Fraternal Order of Police, Lodge 82. Lodge membership dues are $28.00 per month.

Name: __________________________________________SSN: _______________________

Address (1): _________________________________________________________________

Address (2): _________________________________________________________________

Home Phone: ___________________________ Work Phone: ________________________

E-Mail Address: ______________________________________ D.O.B. : ______________

I, ______________________________ hereby authorize the Fraternal Order of Police, Lodge 82, to make withdrawals from my account listed below, including if necessary, to correct credit entries made in error to pay my Lodge dues. I also authorize Inter National Bank to accept such entries. This authorization will remain in effect until I give written notice to change or cancel it.

Routing #: ____________________________________ Account #: _______________________

Signature: _____________________________________ Date: ___________________________

After completing the application, send payment of $28.00 (per capita tax) and all paperwork to the address listed on the header of this form. This application cannot be processed without a voided check. A copy of the per capita tax check can be used in lieu of a voided check.

(Attach voided check, copy of per capita check or savings account slip here-No Deposit Slips)

“Outlaws West of the Pecos”

(rev. 08/06/2006)