Name:                                                                                                     

Address:                                                        City/State                                               Zip

Employer:                                                      Last 4 of Social Security:

Phone  Number:                                          Lodge Name: James/Valley Regional Lodge #4

Personal Email: 

Under the Legal Defense Plan, the year has 4 quarters.  Each quarter has a payment of $81 which is not prorated when you join.  You MUST be a current FOP member to qualify for Legal Defense.  To start Legal Defense please fill out the information below and make payment of $81.00.  This will buy you into the current quarter of the plan.  Once again the quarter is not prorated and is $81.  If you are on payroll deductions, the payroll deductions must start being deducted the same month that your legal defense goes in effect or you will fall behind on payments.  Your payroll deductions should then cover any further payments.  If you choose to be billed separately, you will receive a bill one month prior to the date due.  If you have any questions, you can contact the Local Lodge Treasurer at the email address below.

jamesvalleyndfoplodge4@gmail.com

Quarters run:

  

I understand if payment is not received by the due date, I maybe removed from the Legal Defense Plan and unable to join the plan until payment is received in full.

By submitting this application you agree to these terms and conditions.  Your submittal will act as a signature.