4th Degree Exemplification
State Convention 2026
Choose one of the following:
4th Degree Candidate
Observer
Member Type
New Member
Restoration/ Reinstatement (greater than 7 years)
Are you a US Citizen?
Yes
No
If Yes?
Birth
Naturalization
If not a US citizen, please state country of citizenship?
Name
*
First Name
Middle Initial
Last Name
Membership Number
*
Title
Msgr, Most Rev. Rev. ect.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Supposed to be home phone.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Martial Status
1st Degree Date (If Known)
Council #
Assembly # (if known)
Assembly City
Assembly State
Parish
Diocese
Number of Family Members Joining the Exemplification
Signature
Back
Next
I have read and understand the above Dress Code:
Back
Next
Exemplification Payments
prev
next
( X )
Exemplification Candidate
$50.00
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
State Convention Luncheon
If not already registered for the convention
$45.00
$
45.00
Quantity
1
2
3
4
5
6
7
8
9
10
State Convention Banquet Dinner
If not already registered for the convention
$70.00
$
70.00
Quantity
1
2
3
4
5
6
7
8
9
10
Exemplification Observer
If not already registered for the convention
Free
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Continue
Should be Empty: