Date
Name: DOB: --
Address:
City: State: GA Zip:
Phone:
- E-mail:Agency:
City: State: GA Zip:
Are you retired law enforcement:
Applicant’s Signature_______________________________________
$40 per fiscal year (Oct. 1st- Sept 30th) $20 (If joining within 6 month’s of end of fiscal year (Apr. 1st - Sept. 30th, then $40 to be current for new fiscal year starting Oct.1st) Retired Members: $20 per year
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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
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(Submitted by: Lodge use only)