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
Quantity
1
2
3
4
5
6
7
8
9
10
State Convention Luncheon
If not already registered for the convention
$
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
Quantity
1
2
3
4
5
6
7
8
9
10
Exemplification Observer
If not already registered for the convention
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Continue
Should be Empty: