THE DONALD R. SHEPPARD LODGE No. 122

FRATERNAL ORDER OF POLICE

P.O. BOX 1701 HIGHLAND, INDIANA 46322

APPLICATION FOR MEMBERSHIP

ACTIVE ASSOCIATE Date: ,20

I, , apply for Membership in the Fraternal Order of Police, Donald R. Sheppard (Highland) Lodge #122, and agree to abide by its Constitution and By-laws and the following information is submitted concerning myself:

Full Name: (Please Print) (Mr.,Mrs.,Miss)

Last First Middle

Present Address:

Street Address City State Zip

Telephone: Date of Birth: Age: Occupation:

Employer’s Name: Address:

Have you ever been arrested other than having a Traffic Citation?

If yes, please explain the charges and circumstances of the arrest on the reverse side.

Have you ever been denied Membership into the Fraternal Order of Police?

I swear that the above information is true to the best of my knowledge, and that this information will be held in confidence, and I understand that if I am accepted into the Fraternal Order of Police, I will support the Lodge and bring credit upon the Membership of the Lodge.

I further understand that all emblems and decals furnished me by the Lodge, are the property of the Lodge, and if my membership is revoked or I choose to withdraw my membership, I shall return such emblems and decals to the Lodge.

Enclosed, find my initiation fee of $5.00 and Dues of $25.00.

Signature:

Recommended and vouched for on the honor of Brother:

The Investigation Committee has investigated the above applicant, and recommends that Applicant be (Accepted) or (Denied) Membership into the Fraternal Order of Police, Highland Lodge #122.

FOR SECRETARY USE:

Fee Received: Proposed: Elected on: Emblem No.