Legal Aid Plan Application/Enrollment Tennessee State Lodge Legal Aid Plan Name(Required) First Last Email(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Work Phone(Required)Lodge Name and Number(Required)Last 4 of SocialEmployer/Agency:(Required)I hereby apply for enrollment in the Tennessee State Lodge Legal Aid Plan. I agree to abide by all of the terms and conditions thereof. I understand that my coverage will not be effective until the receipt of my payment to the Plan and acceptance by the Legal Aid Committee of the Tennessee State Lodge Fraternal Order of Police. To my knowledge I am not presently named in any suits, actions, or proceedings, not under investigation for a duty related incident except for the following:CommentsSignature(Required)Date MM slash DD slash YYYY Annual Fee Price: Copy Send a copy of the complete plan document
