Dispensation Request Form

Dispensation Request Form
Email
Choose Action
Select Lodge or Chapter
Select Email
Event Details
Name of Event
Event Type
The completion of this application is necessary when requests are presented for any dispensation along with all applicable fees. All applicable fees must be sent to Most Worshipful Prince Hall Grand Lodge of Tennessee P.O. Box 161066, Memphis, TN 38186 Failure to meet these requirement s may result in denial of request.
Description of Event
Include Event Location, and the Insurance Policy Number (If Required)
Event Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Event Start Time

Hour Minutes

AM/PM Option
Event End Time

Hour Minutes

AM/PM Option
DDGM Approve Event

(DDGM ONLY)
Event Approved or Declined (DDGM ONLY)
DDGM Comments
Should be Empty:

Event Details