Assoc Name Change Form

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FRATERNAL ORDER OF POLICE

STATE LODGE OF MICHIGAN

ASSOCIATE MEMBERSHIP FORM

NAME CHANGE

***********PLEASE PRINT CLEARLY***********

NAME AS LISTED ON ASSOCIATE ROSTER:

_____________________________________________________________________________

CHANGE TO:

______________________________________________________________________________

NAME AS LISTED ON ASSOCIATE ROSTER:

_____________________________________________________________________________

CHANGE TO:

______________________________________________________________________________

NAME AS LISTED ON ASSOCIATE ROSTER:

_____________________________________________________________________________

CHANGE TO:

______________________________________________________________________________

NAME AS LISTED ON ASSOCIATE ROSTER:

_____________________________________________________________________________

CHANGE TO:

______________________________________________________________________________

NAME AS LISTED ON ASSOCIATE ROSTER:

_____________________________________________________________________________

CHANGE TO:

______________________________________________________________________________

NAME AS LISTED ON ASSOCIATE ROSTER:

_____________________________________________________________________________

CHANGE TO:

______________________________________________________________________________

NAME AS LISTED ON ASSOCIATE ROSTER:

_____________________________________________________________________________

CHANGE TO:

______________________________________________________________________________

LODGE # ______ DATE: _____________ SECRETARY: _______________________________________

Category: MIFOP