I, apply for membership as an Associate Member of the Fraternal Order of Police, Indianapolis Lodge N. 86, and the following information is submitted concerning myself.

Have you ever been convicted of a misdemeanor or felony? If the answer is 'yes', please note the charge, date, location, and final sentencing disposition.

In Indiana, an individual's criminal history is protected by state law. Under Indiana Code 5-2-5-1, an individual has a right not to have his/her criminal history released to unauthorized persons. By signing this form, you are acknowledging that right and allowing the FOP to acquire your criminal history on your behalf. Your intention is to allow the FOP to utilize your criminal history for the purposes of attaining membership in the FOP.

Have you ever been denied membership into the Fraternal Order of Police?    Yes No   

I swear that the above information is true to the best of my knowledge and that this information will be held in confidence and I understand that if I am accepted into the Fraternal Order of Police, I will support the Lodge and bring credit upon the Membership of the Lodge.

I further understand that all emblems and decals furnished me by the Lodge are the property of the Lodge, and if my membership is revoked or I choose to withdraw my membership, I shall return such emblems and decals to the Lodge.