Lodge Renewal Form

The Loyal Lodge of Ondessonk & Tekakwitha

Lodge Membership Renewal
Name*

First Name Last Name
Maiden Name
If applicable
Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail*
example@example.com
Phone Number:*

Area Code Phone Number
Year Inducted into Lodge
If you are renewing dues for more than one Lodge member who lives at the same address, please list their name(s) and year of induction below.

Lodge Dues & Sash

Lifetime Lodge Membership$250.00

Lodge Member Ages 10-24$10.00

Quantity

Lodge Member Ages 25+$20.00

Quantity

Lodge Sash$15.00

Quantity

Total $0.00