| Membership
Information |
| Name: |
| Last |
|
| First |
|
| Middle |
|
| Residence
Address: |
| Street |
|
| City |
|
| State |
|
| Zip |
|
| Mailing
Address: |
| Street |
|
| City |
|
| State |
|
| Zip |
|
| Phones: |
| Home |
|
| Office |
|
| Pager |
|
| Mobile |
|
| Fax |
|
| Email: |
| Home |
|
| Other |
|
| Personal
History: |
| Birthday |
|
| Marital
Status |
|
| Wife's
Name |
|
| Children's
Names & Ages |
|
| Your
Profession |
|
| Job
Title or Position |
|
| Employer's
Name & Address |
|
| Masonic
History: |
| Dates: |
|
| Entered
Apprentice |
|
| Fellow
Craft |
|
| Master
Mason |
|
| Lodge
Name & Number |
|
| Lodge
Address |
|
| Street |
|
| City |
|
| State |
|
| Zip |
|
| Lodge
Name & Number |
|
| Lodge
Address |
|
| Street |
|
| City |
|
| State |
|
| Zip |
|
| Lodge
Offices Held |
|
| Grand
Lodge Offices Held |
|
| Certified
Lecturer |
(
Yes ) or ( No ) |
| When? |
|
| If
not certified, what memory work do you do? |
| |
| DDGL? |
|
| When? |
|
| DDGM? |
|
| When? |
|
| Membership
in other Masonic Bodies |
| York
Rite |
|
| Scottish
Rite |
|
| Shrine |
|
| Others |
|
| Offices
Held |
|
| Personal
Interests: |
| Youth
Organizations |
|
| Office
or Position |
|
| Civic
Organizations |
|
| Office
or Position |
|
| Church |
|
| Office
or Position |
|
| Skills: |
| Photography |
(
Camera ) ( Digital ) ( Video ) |
| Drama |
(
Actor ) ( Director ) ( Lights ) ( Props ) |
| Music |
(
Soloist ) ( Band ) ( Choir Member ) |
| Instrument(s)
Played |
|
| Computer
Skills |
(
Operator ) ( Programmer ) ( Repair ) |
| Sports |
|
| Miscellaneous |
(
Plumbing ) ( Heating ) ( Air Conditioning )
(
Electrical ) ( Carpentry ) ( Medical )
(
Yard Work ) ( Public Speaking )
( Cooking ) ( Cleaning )
(
Coin or other Collection )
|
| Other
Interests or Talents |
|
| Lodge
Service Interests and Willingness to Serve in the Following Capacity: |
| Lodge
Officer |
|
| Committee
Chairman |
|
| Committee
Member |
|
| Coach
for Candidates |
|
| Visitation
Committee |
|
| Meal
Preparation |
|
| Serve
Meals |
|
| Refreshment
Committee |
|
| Investigating
Committee |
|
| Newsletter |
|
| Transportation
Committee |
|
| Charity
Committee |
|
| Publicity/
Public Relations Committee |
|
| Telephone
Committee |
|
| Degree
Team |
|
| Other |
|
| |
|
| |
|
| Date
Form Completed: |
|