To the Officers of the Fraternal Order of Police:
I the undersigned, a full time, regularly employed or retired law enforcement officer in good standing, do hereby make application for an Active Membership in CHINOOK LODGE NO. 21
If my membership should be revoked or discontinued for any cause other than retirement while in good standing, I hereby agree to return to said Lodge my membership card and any other material bearing the F.O.P. insignia (i.e.such as an auto emblem, lapel pin, etc.)
(Signed)___________________________________________(Date)_____________________
Applicant's Name______________________________D.O.B._____________ SSN________________
Current Dept.____________________ Yrs. Of Service in LE______
Address___________________________________
City/State___________________________ Zip____________ E-Mail______________________
Phone(H)_____________________ (W)__________________ Lodge Sponsor___________________
Spouse_____________________________

1) Membership Chairman Recommendation: Yes_______ No_______ Initials________
2) Did Applicant enclose: ( ) Annual Dues Legal Defense Plan ( )Yes ( )No Ck ( ) Cash ( )
3) Applicant notified to appear at the next lodge meeting on : ______/______/______Initials___
Membership Chairman: Forward Application to Lodge Secretary Date___/___/___ Initials___
4) Applicant appeared at lodge meeting as requested? YES_____ NO____
5) Was Applicant approved for membership? YES____ NO____ Date ____/____/____ Initials____
6) New member sworn in? YES____ NO___ Date ____/____/____ Initials_____
7) Did member pay: Annual dues? YES___ NO___ Date________ Initials_____
Legal Defense Plan? YES___ NO___ Date________ Initials_____
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