Petition for Affiliation

Petition for

Affiliation or Dual Membership

I,

First

Middle

Last

the petitioner, reside at

City

State/Province

Zip/Postal

Country

Email

Date of Birth

Place of Birth

I was Initiated on

Passed on

Raised on

in

Lodge Name

Lodge No.

Located at

in the State/Province of

and am now a member in good standing in

Lodge Name

Lodge No.

located in

in the State/Province of

My dues are paid to

A Dimit or Certificate of good standing accompanies this petition (if membership is being retained in more than one lodge, a letter or certificate of good standing must be furnished for each lodge in which membership is being retained). At the present time I have membership in the following lodges in this or another Jurisdiction.

List the lodges where you maintain membership.

Branch of Military Service

Date of Marriage

Place of Marriage

Wife’s Maiden Name

Wife's Maiden Name

First

Middle

Last

Names and Addresses of three next of kin

If this Petition is for dual membership, I thoroughly understand that I must maintain good standing in ALL Lodges, and that loss of membership or good standing in one Lodge may jeopardize my membership in any other.

I plan on retaining my membership in

and all other Lodges in which I have membership in other Jurisdictions.

Date

Signature

To be signed at the Lodge

Recommended by

Submission of Original Work

Maximum upload size: 516MB

Dates of:

Reception:
Report:
Balloting:
Result of Ballot:
Petitioner Notified:
Signed Bylaws:
If Petition was declined, refund was sent on:

Fees:

Affiliation Fee:  $100
Dues for Current Year:  $130
Total:  $230


Referred to Brothers: