Application for Membership Form

Application for Membership Form

APPENDIX A
Personal Information
Name

First NameMiddle Name(s)Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Country
Masonic Information
Admission Type

ElectedRe-Admitted
Date of Birth

MonthDayYear
Date
Declaration
I hereby agree, if elected a Member of the Society, to abide by the Rules and Regulations which have been or may hereafter be adopted. I also further authorize the Society to solicit from my Mother Lodge or any other appropriate organization my basic demographic information for its sole use in seeking to source and provide services on my behalf.
Do you agree?

I agree
Beneficiary and Emergency Contact
I do hereby nominate the below named person as my Beneficiary to receive any sum of money which may become payable by the Society by reason of my death.
Beneficiary Name

First NameMiddle Name(s)Last Name
Beneficiary Address
I do hereby nominate the below named person as my Emergency Contact, to be contacted in case of any emergency pertaining to myself.
Emergency Contact Name

First NameMiddle Name(s)Last Name
Emergency Contact Address
Signature and Submission
Signature

Clear
Please verify that you are human*
Should be Empty:

Personal Information