Indiana State Fraternal Order of Police

Losses in Membership Report

Please provide the following contact information (* = Required Field):

Lodge Name/Number:	* Please enter Lodge Name/Number
Lodge Address:
City:
State:
Zip Code:
Lodge Phone:
Lodge FAX:

Member 1 Information

Name:	* Please enter Member Name
Reason:	* Please enter loss reason
Membership #:	* (Please use membership roster to obtain membership #.) Please enter Membership #

Member 2 Information

Name:
Reason:
Membership #:	(Please use membership roster to obtain membership #.)

Member 3 Information

Name:
Reason:
Membership #:	(Please use membership roster to obtain membership #.)

Member 4 Information

Name:
Reason:
Membership #:	(Please use membership roster to obtain membership #.)

Member 5 Information

Name:
Reason:
Membership #:	(Please use membership roster to obtain membership #.)

Enter the text shown in the image above.