Membership Form

Type of Membership*

Associate Membership ($25/year)
Active Membership ($4.25/month)

Personal Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Mobile Phone*

Personal email*

Date of Birth*

Sex*

Male
Female

Employment Information

Employer*

How many years?*

Duty Title*

Division*

Employer Address*

Street Address Address Line 2 City State ZIP Code

Law Enforcement Credentials*

Drop files here or

Accepted file types: doc, docx, png, gif, png, pdf, Max. file size: 256 MB, Max. files: 4.

Please upload a copy of your Active Duty or Retired Law Enforcement Credentials (doc, docx, jpg, gif, png, or pdf). 64MB maximum file size please.

Signature*

Payment Information

Payment method*

Check
Cash

Payment method*

Check
Cash
Bank Draft

SCFOP Lodge 12 Membership Dues
MONTH	AMOUNT DUE
August	$51.00
September	$46.75
October	$42.50
November	$38.25
December	$34.00
January	$29.75
February	$25.50
March	$21.25
April	$17.00
May	$12.75
June	$8.50
July	$4.25

Please make checks payable to Coastal Carolina F.O.P. Lodge 12 and mail to:

Coastal Carolina F.O.P. Lodge 12
PO Box 8455
Myrtle Beach, SC 29578

Members are responsible for all returned checks and bank draft fees.

Transactions will appear as SCFOP12 on your bank statement.

Please make checks payable to Coastal Carolina F.O.P. Lodge 12 and mail to:

Coastal Carolina F.O.P. Lodge 12
PO Box 8455
Myrtle Beach, SC 29578

Members are responsible for all returned checks and bank draft fees.

Transactions will appear as Coastal Carolina on your bank statement.

BY NOT PARTICIPATING IN A BANK DRAFT, I AGREE TO MAKE ANNUAL PAYMENTS TO COASTAL CAROLINA 12, FRATERNAL ORDER OF POLICE FOR MY DUES AND/OR LEGAL DEFENSE FUND DUES. I ALSO UNDERSTAND THAT I MAY START A BANK DRAFT AT A LATER DATE, IF I SO CHOOSE. I HEREBY AGREE TO KEEP ON DEPOSIT IN THE ABOVE ACCOUNT, SUFFICIENT FUNDS TO PAY SUCH DRAFTS THAT I HAVE AUTHORIZED AND TO INDEMNIFY COASTAL CAROLINA LODGE 12, FOP, AND SOUTH STATE BANK, FROM ANY LOSS WHATSOEVER ARISING FROM AN OVERDRAFT OF MY ACCOUNT WITH THE ABOVE STATED INSTITUTION. SHOULD COASTAL CAROLINA LODGE 12, FOP, AND/OR SOUTH STATE BANK SUSTAIN ANY LOSS, THEY MAY CHARGE THAT LOSS AGAINST ANY ACCOUNT I HAVE OR TAKE OTHER STEPS TO MAKE COLLECTION AS THEY MAY DEEM NECESSARY.

Please submit all cash payments to Robert Bell or an Elected Officer.

BY NOT PARTICIPATING IN A BANK DRAFT, I AGREE TO MAKE ANNUAL PAYMENTS TO COASTAL CAROLINA 12, FRATERNAL ORDER OF POLICE FOR MY DUES AND/OR LEGAL DEFENSE FUND DUES. I ALSO UNDERSTAND THAT I MAY START A BANK DRAFT AT A LATER DATE, IF I SO CHOOSE. I HEREBY AGREE TO KEEP ON DEPOSIT IN THE ABOVE ACCOUNT, SUFFICIENT FUNDS TO PAY SUCH DRAFTS THAT I HAVE AUTHORIZED AND TO INDEMNIFY COASTAL CAROLINA LODGE 12, FOP, AND SOUTH STATE BANK, FROM ANY LOSS WHATSOEVER ARISING FROM AN OVERDRAFT OF MY ACCOUNT WITH THE ABOVE STATED INSTITUTION. SHOULD COASTAL CAROLINA LODGE 12, FOP, AND/OR SOUTH STATE BANK SUSTAIN ANY LOSS, THEY MAY CHARGE THAT LOSS AGAINST ANY ACCOUNT I HAVE OR TAKE OTHER STEPS TO MAKE COLLECTION AS THEY MAY DEEM NECESSARY.

Bank Information

Name of Bank*

Routing Transit Number*

Account Number*

Draft From*

Checking
Savings

Monthly Membership dues in the amount of $4.53 will be deducted from your account.

Date to Start Draft*

Please provide a picture of a voided check*

Max. file size: 8 MB.

Please upload a copy of a voided check (jpg, gif, png, or pdf). 8MB maximum file size please.

Members are responsible for all returned checks or draft fees.

Transactions will appear as Coastal Carolina on your bank statement.

BY NOT PARTICIPATING IN A BANK DRAFT, I AGREE TO MAKE ANNUAL PAYMENTS TO COASTAL CAROLINA 12, FRATERNAL ORDER OF POLICE FOR MY DUES AND/OR LEGAL DEFENSE FUND DUES. I ALSO UNDERSTAND THAT I MAY START A BANK DRAFT AT A LATER DATE, IF I SO CHOOSE. I HEREBY AGREE TO KEEP ON DEPOSIT IN THE ABOVE ACCOUNT, SUFFICIENT FUNDS TO PAY SUCH DRAFTS THAT I HAVE AUTHORIZED AND TO INDEMNIFY COASTAL CAROLINA LODGE 12, FOP, AND SOUTH STATE BANK, FROM ANY LOSS WHATSOEVER ARISING FROM AN OVERDRAFT OF MY ACCOUNT WITH THE ABOVE STATED INSTITUTION. SHOULD COASTAL CAROLINA LODGE 12, FOP, AND/OR SOUTH STATE BANK SUSTAIN ANY LOSS, THEY MAY CHARGE THAT LOSS AGAINST ANY ACCOUNT I HAVE OR TAKE OTHER STEPS TO MAKE COLLECTION AS THEY MAY DEEM NECESSARY.

I herby authorize my bank account to be charged. Please sign.*

Name

This field is for validation purposes and should be left unchanged.

Membership Form

Personal Information

Employment Information

Payment Information

SCFOP Lodge 12 Membership Dues

Bank Information