If you wish to complete this form by hand please click here

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email Address

Sex

Drivers License Number

State

Spouse

If married

Are you a U.S. Citizen?

If no, are you a legal resident of the United States?

Occupation

If retired, former occupation

Employer

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you own or are you a partner in this business?

Have you ever been convicted of, plead guilty to, or been given a fine, penalty, or probation for a crime (other than a minor traffic offense not punishable by incarceration)?

If yes, please explain

Do you have any outstanding traffic or criminal charges?

If yes, please explain

Are you now, or have you ever been party to any litigation or complaint against any active or retired Montgomery County law enforcement officer?

If yes, please explain

Are you now, or have you ever been, an Associate or Active Member of any FOP Lodge?

If yes, Lodge Name & City

Are you related by blood or marriage to any active or retired Montgomery County law enforcement officers?

(Includes Montgomery County Police, Montgomery County Deputy Sheriffs, Gaithersburg City, and Takoma Park)

If yes, please provide name(s) and Department

Do you personally know any active or retired Montgomery County law enforcement officers?

(Includes Montgomery County Police, Montgomery County Deputy Sheriffs, Gaithersburg City, and Takoma Park)

If yes, please provide name(s) and Department

If numerous, please list two

Have you ever been employed by Montgomery County, any Montgomery County- funded agency, Gaithersburg City, or the City of Takoma Park?

If yes, please provide department or agency and approximate dates of employment.

Please briefly state why you desire to become an Associate Member of Lodge 35.