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COMBINED FORM
I~
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To the Chapter,
Council & Commandery
MIDDLE (FULL)
FIRST
LAST
Comprising the Bodies of the
BIRTHDATE
PLACEOF BIRTH
AGE
FULL
NAME
(PRIND
RESIDENCEADDRESS
CITY
OCCUPATION
EMPLOYER
HAVEYOU EVERBEEN
REJECTEDBYA CHAPTER
COUNCIL OR COMMANDERY?
NO
YES
0
0
ZIPCODE
STATE
BUSINESSPHONE
LENGTHOF TIMEIN CONTINUOUS RESIDENCE
NAME WHICH & WHEN IFANSWERED"YES·
INTHIS
STATE
STATEOF
I AM PRESENTLY
A MEMBERIN GOOD STANDINGOF
o
COUNCIL
FORDEGREESAND MEMBERSHIP
0
NO.
0
RECOMMENDED BY
AND
0
0
_
CHAPTER
The undersigned
represents that all of the above statements
are correct and that he is desirous of receiving (or. if for affiliation or reinstatement
onlv.he has already received)
the Cryptic
Degrees as conferred
in this Council and, if he becomes
a member,he
will cheerfully
comply
with all the laws, ancient customs and usages of the Fraternity,
_
_
SIGNATURE
AND
X
."...,...,-(FIRST.MIDDLE & LAST NAME IN FULL)
X
-----=__---:-:-------------
(FIRST,MIDDLE & LAST NAME IN FULL)
COUNCIL FEEIS$
WITH$
ATTACHED.
BALANCE (IFANY) WILLBEPAID PRIORTO CONFERRA'"'L-=O::-:F:-:D:-::E-=-G::"CRE=E""S,--
RECOMMENDED BY
DUES
ATTACHED
FOR REINSTATEMENT
S
_
SIGNATURE
AND
DUES
ATTACHED
FOR REINSTATEMENT
S
The undersigned
represents that all of the above statements
are correct and that he is desirous of receiving (or, if for affiliation or reinstatement
only, he has already received)
the Capitular Degrees as conferred
in this Chapter
and, if he becomes
a member. he will cheerfully
comply with all the laws, ancient customs and usages of the Fraternity.
CHAPTERFEEISS
WITHS
ATTACHED.
BALANCE (IFANY) WILL BEPAID PRIORTO CONFERRA:7L--::O:C:FC::D"'EGocR=E=ES=-.--
RECOMMENDED BY
DUES
ATTACHED
FOR REINSTATEMENT
$
K.T. at
NO.
FORTRANSFER
OF MEMBERSHIPBYAFFILIATION·
• DEMITATTACHEDHERETO
at
R. & S.M at
FORTRANSFER
OF MEMBERSHIPBYAFFILIATION"
COMMANDERY
FORORDERSAND MEMBERSHIP
o
FORTRANSFER
OF MEMBERSHIPBYAFFILIATION"
To:
o
R.A.M.
CHAPTER NO.
To:
TO THEOFFICERSAND MEMBERSOF THE
BODY (OR BODIES)NAMED BELOW:
20
DAYOF
To:
0
STATEOF
COMMANDERY NO.
ISHEREBYMADE ON THIS
FOR DEGREESAND MEMBERSHIP
I "
51
THIS YEARS MONTHS
YEARS MONTHS IN
CITY
COUNCIL NO.
CHAPTER NO.
o
I ,I
I AM PRESENTLY
A MEMBERIN GOOD STANDINGOF
LODGE NO.
'Petiti<m
HOME PHONE
COUNCIL
The undersigned
represents that all of the above statements
are correct.
believer in the CHRISTIAN RELIGION and that he is desirous of receiving
(or,
reinstatement
only, he has already received)
the Orders of Knighthood
as
Commandery
and, if he becomes
a member, he will cheerfully
conform
to
cient customs and usages of the Order.
_
that he is a firm
if for affiliation or
conferred
in this
all the laws, an-
_
SIGNATURE -COMMANDERY FEEISS
WITH$
ATTACHED.
BALANCE (IFANY) WILL BEPAID PRIORTO CONFERRA"CL--=O"'F--=O"'R-=-D-ERS:-:--.
--
__
---,-==----::-:-::-:_.,-(FIRST,MIDDLE & LAST NAME IN FULL)
X
COMMANDERY