North Carolina Fraternal Order of Police Old North State Statewide Lodge 100

Membership Application

First Name *

Middle Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Birth Date * +

Social Security Number (Last 4) *

Email Address (PLEASE DO NOT USE AN AGENCY EMAIL. USE YOUR PERSONAL EMAIL) *

Law Enforcement Status *

Full Time Active

Reserve

RETIRED LEO

Are you BLET Certified or Federal Law Enforcement Certified *

Yes, BLET Certified

Yes, Federal Law Enforcement Certified

No, Not Certified BLET or Federal Law Enforcement

Agency Name or Retired From *

Agency Address: Street or PO *

City, State, Zip *

Driver's License Number *

State of Issuance of Driver's License *

Beneficiary Name (s) *

Relationsship *

Beneficiary Phone Number *

Beneficiary Address: Street, City, Zip *

Terms and Conditions *

You consent to receive communications from us electronically. We will communicate with you by e-mail or phone. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.

Please upload a Photo of your Driver's License *

Please upload a Photo of your Law Enforcement Credentials *

By Clicking the "I accept box" I, in the presence of the Creator of the Universe and the members of the Fraternal Order of Police, do most solemnly and sincerely promise and swear, that I will to the best of my ability comply with all the laws and rules of this Order; that I will recognize the authority of my legally elected officers and obey all orders therefrom not in conflict with my religious or political views, or my rights as an American citizen; that I will not cheat, wrong or defraud this Order, or any member thereof, or permit the same to be done if in my power to prevent it; that I will at all times aid and assist a worthy Brother or Sister in sickness or distress, so far as it lies in my power to do so; that I will not divulge any of the secrets of this Order to anyone not entitled to receive them. To all of which I most solemnly and sincerely promise and swear. Should I violate this, my solemn oath or obligation, I hereby consent to be expelled from the order. *

I accept

Name on card you will be using for payment *

By clicking below, I understand that my card will be charged $60.00 and then $20.00 per month. If I wish to cancel my membership, I understand I must provide 30 days' notice in writing to stop payments. If my card is declined or payment is not approved, coverage will not begin until approval has been acquired by the NCFOP. *

By clicking the this selection, I am acknowledging and approving the NCFOP to charge my card.

Payment *

Membership $60.00 to join and the $20.00 each month thereafter