Virginia Beach FOP Lodge #8

Application for Membership and/or Legal Defense

 Please print neatly:  ($50.00 regular membership $36.00 for Retired)

FOR MEMBERSHIP ONLY

Applicant’s Name: _______________________________________________________

Address: _____________________________________City:______________________

State: ___________   Zip: __________ Phone: _______________ DOB: ___________

SSN: __________________ Title__________________ E-mail ___________________

Applicant's Department: __________________________________________________

Beneficiary Name: _______________________________________________________

Sponsor’s Name: ________________________________________________________  

Sponsor's Phone #: __________________________

TO INCLUDE LEGAL DEFENSE

Option #1:  Direct Withdrawal from city paycheck

(Only for Virginia Beach Employees)

Please complete the attached Virginia Beach City Payroll Direct Deposit Request.  Please fill in your name, SSN, phone, the effective date you want the withdrawal to begin (at least two week from today’s date) and sign the form at the bottom.  Return this form with your application and it will be processed through the lodge and the city finance department. This payment will be $20.00 per month and will cover your enrollment in legal defense and membership to the Lodge #8

Option #2:  Yearly Payment Plan

(For none city employees or those who do not wish to have direct withdrawal)

Effective (Date) ________________, please enroll me in the Virginia Beach FOP Lodge #8’s Legal Defense Plan.  I understand that I will be required to make a yearly payment of $240.00 on or before July 1st each year to cover the expense of the Legal Defense and my membership to Lodge #8.  Pro-rated rates are available to join throughout the year.

 I, the undersigned, a full-time regularly employed law enforcement officer, do hereby make application for active membership in the Fraternal Order of Police.  If my membership should be revoked or discontinued for any cause other than retirement while in good standing I hereby agree to return to the Virginia Beach Lodge #8 my membership card and any other material bearing the FOP insignia, such as auto emblem, pin, etc.

 Signature: _____________________________________ Date: _________________

Official Use Only:   Approved ___________ Date ________________________

Secretary Signature: ___________________________________________________