MWPHGL of IN 167th Grand Lodge Session Registration Form

Date

Choose Highest Current Title*

First Name*

Please Enter your First Name and Middle Initial after your Pre-Filled Title

Last Name*

Please Enter your Last Name and Suffix (i.e. Jr, Sr,) if applicable

E-mail*

QR Value

Lodge Name & Number*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Mobile Phone Number*

Home Phone Number if different from above

Do you prefer to receive Grand Lodge Communications via E-Mail or Post Office?*

Choose your Registration Option below*

Blue House Only - $125.00Blue House & OES - $145.00Extra Banquet Ticket - $65.00

Total Registration Fees Due

Choose Method of Payment below*

To pay using another method click the URL on the thank you page, you will not be registered until payment is received.Apple Pay, Cash Pay, Google Pay, Debit or Credit Card Secure Payment through SquareMailing my Registration Payment to address below

Registration Credit Card Payment

Blue House Registration Fee due before July 1, 2023$125.00

Blue House Registration Only

Quantity
Item subtotal:$0.00

Blue House & OES Registration Fee due before July 1, 2023$145.00

Blue House & OES Registration

Quantity
Item subtotal:$0.00

Extra Banquet Ticket Fee due before July 1, 2023$65.00

Extra Banquet Ticket

Quantity
Item subtotal:$0.00

Total $0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Your registration payment must be received before July 1, 2022. All mail in payments should be made out to MWPHGL of IN if you are paying with a cashiers check, check or money order. Mail them to the RW Grand Secretary Jeffrey D. Mathis at P.O. Box 26104, Indianapolis, IN 46226.

Voting Member

YES

Most Worshipful Prince Hall Grand Lodge of Indiana 167th Annual Session

July 23-25, 2023 Registration Form at Marriott East, 7202 East 21st Street, Indianapolis, IN 46219

Registration Deadline is July 1, 2023

Payment Methods