P. O. Stephen P. Driscoll Memorial Lodge
NEW YORK STATE FRATERNAL ORDER OF POLICE
PO BOX 7, CARMEL, NEW YORK 10512
Phone: 845-222-0916 / Fax: 845-223-4711
E-mail: fopdriscoll@usa.com / Website: www.fopdriscoll.com


AUXILIARY APPLICATION:
Please Complete this form and submit your payment on the next page.
*First Name:
*Last Name:
*Alias/Nickname:
*E-Mail:
*Address:
*Apartment/Suite #:
*City:
*State:
*Zip:
*Home Phone:
*Cell Phone:

AUXILIARY INFORMATION:
(Relatives of Law Enforcement Personnel)

*Law Enforcement Officer:
Your Relationship:
*Officer's Dept:
*Officer's Lodge:
BENEFICIARY INFORMATION:
*First Name:
*Last Name:
*Relationship:
*D.O.B:
Above must be completed or benefits will be paid to the estate
*Required