| FOP Lodge 76 | |||||||||
| Membership Information Sheet | |||||||||
| Name:___________________________________________________________________ | |||||||||
| Home Address:____________________________________________________________ | |||||||||
| City:_____________________________ State:________________Zip:_______________ | |||||||||
| Dury Assignment:______________________________Rank:______________________ | |||||||||
| Email Address:____________________________________________________________ | |||||||||
| Home Phone:_____________________________________________________________ | |||||||||
| Pager/Cell:_______________________________________________________________ | |||||||||
| Date of Birth:_____________________________________________________________ | |||||||||
| Social Security #:__________________________________________________________ | |||||||||
| Please complete a new form and forward to FOP 76 whenever the above | |||||||||
| information changes. | |||||||||
| (new members include a payroll deduction form indicating FOP 76 as the | |||||||||
| deduction in the amount ($11.00) | |||||||||
| Fraternal Order of Police, State Police Lodge 76 | |||||||||
| 9004 Harford Rd. | |||||||||
| Baltimore, Md 21234 -----------Phone 410-668-7677 | |||||||||
| Visit us at FOP76.ORG | |||||||||
| Please provide an email address so we can send you information as necessary. | |||||||||
| Or Email addresses / changes to FOP76@VERIZON.NET | |||||||||