NEW MEMBER APPLICATION

MEMBER INFORMATION
First Name:*
Last Name:*
Middle:
Date of Birth:
Address:
City:
State:
Zip:
Phone:*
Email:*
Please do not use a government email address (.gov)
AGENCY INFORMATION
Agency:
City:
State:
Zip:
Are you a Retired Law Enforcement Officer:
- Yes*
- No
*Retired Members receive a discounted rate of $50/year. Retired Applicants will need to submit a copy of their retired credentials with their application.
Dues Information
Please select your membership type and/or enroll in the Officer Injury and Illness Fund
Membership Dues*
- Regular Member | $95/year (PAID ONLINE)
- Regular Member | $95/year (DIRECT DEPOSIT at 3.66 Bi-weekly - only Forsyth County Employees)
- Retired Member | $50/year (PAID ONLINE)
- None
Officer Injury and Illness Fund*
- Yes - Enroll Me | $200/year (PAID ONLINE)
- Yes - Enroll Me | $200/year (DIRECT DEPOSIT at $7.69 Bi-weekly - only Forsyth County Employees)
- No - Do Not Enroll Me
Total Paid Online
$0.00
BENEFICIARY INFORMATION
If you are enrolling in the Officer Illness and Injury Fund, please complete the information below.
Full Name of Beneficiary #1:
Note: You Only need one beneficiary, if you would like to name two please indicate the percentage for each.
Relationship:
D.O.B.
Percent:
Address:
City:
State:
Zip:
Full Name of Beneficiary #2:
Relationship:
D.O.B.
Percent:
Address:
City:
State:
Zip:
Electronic Signature*
I, the applicant for Lodge Membership, warrant the truthfulness of the information provided in this application. I understand that my electronic signature (above) constitutes a legal signature confirming that I acknowledge and agree to the Terms of Acceptance.
Total Paid Online
$0.00
This does not include your Direct Deposit amount. Please note: Direct Deposit is only available to Forsyth County employees at this time. If paying by Direct Deposit, you must also complete and return the Forsyth County Direct Deposit Form found on the "Become a Member" page of the website. Forms should be turned in to Captain Silveous.

SGT. D.P. Land Memorial Lodge #82
Fraternal Order Of Police

foplodge82@gmail.com

SGT. D.P. Land Memorial Lodge #82
Fraternal Order Of Police

foplodge82@gmail.com

Mailing Address:
Post Office Box 1374
Cumming, Georgia 30028

Physical Address:
248 Castleberry Industrial Dr
Cumming GA 30040

New Member Application

MEMBER INFORMATION

AGENCY INFORMATION

Dues Information

BENEFICIARY INFORMATION