Membership Signup Form

Membership Type

Active membership is for sworn law enforcement officers. Associate is for non-sworn supporters. Active w/ Legal Defense includes coverage by the SC FOP Legal Defense Plan.

First Name

Middle Name

Optional

Last Name

Street Address

Address Line 2

Apartment, suite, unit, etc.

City

State

ZIP Code

Phone

Personal Email

Date of Birth

Sex

Employer

Years of Service

How many years with this employer?

Duty Title

Division

Optional

Employer Street Address

Employer City

Employer State

Employer ZIP

Law Enforcement Credentials

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Upload a clear copy (front and back if applicable) of your Active Duty or Retired Law Enforcement credentials. Accepted formats: PDF, JPG, PNG. Maximum 10 MB per file, up to 2 files.

Payment Method

Dues Only: $4.25/mo (Check/Cash) or $4.53/mo (Bank Draft). Dues + Legal Defense: $25.85/mo (Check/Cash) or $26.13/mo (Bank Draft). Bank Draft adds a $0.28 monthly processing fee.

Bank Draft Authorization (only if paying by Bank Draft)

If you chose Bank Draft above, provide your bank name, routing number, account number, and whether it's Checking or Savings. You'll also need to mail a voided check to the lodge to complete authorization. Leave blank if paying by check or cash.

Last 4 of Social Security Number

Required only for Active Membership with Legal Defense. Leave blank otherwise.

Lodge Number

If applying for Legal Defense Plan. Default is 12.

Legal Defense Payment Arrangement

If paying by check, make payable to: SC Fraternal Order of Police Legal Defense Plan.

Electronic Signature

Type your full legal name to certify that the information above is true and accurate to the best of your knowledge. By submitting this form, you authorize Coastal Carolina Lodge 12, FOP to process your membership application.

Date