www.gafop102.org
_____________
Date
Name: _______________________________________________________
Address:_____________________________
City:
_____________State:______Zip:_________
Phone:______________________
E-mail:________________________________
DOB: _______________________________
Agency:____________________/________________City________________State:______Zip:_____
C
o
Corrections/Probations
Check if
retired law enforcement: Yes___
No___
Applicant’s
Signature_______________________________________
$30
per fiscal year (Oct. 1st-
Sept 30th) $20 (If joining
within 6 month’s of end of fiscal
year (Apr. 1st - Sept.
30th, then $30 to be current for new
fiscal year starting Oct.1st)
Retired Members: $20 per
year
All
member’s of the FOP receive a $1000
life insurance policy as part of
their membership
_____________________________________________________________________________________
Beneficiary
Information
Name of
Beneficiary(s):________________
Street
Address:__________________________
City/State:_________________
Zip:_________
_____________________________________________________________________________________
Mail dues
to:
Mary Barnes
C/O Treasurer GA FOP Lodge 102
P.O. BOX 203 WAYCROSS, GA 31501
Please
make your check or money order
payable to
Georgia
State Corrections Lodge #102
____________________________________________________________________________________
If you are
interested in joining the Legal
Defense Plan please contact the
Georgia State Lodge for cost and
more information.
1-800-305-0237
__________________________________________
(Submitted
by: Lodge use only)
