INSTRUCTIONS

INSTRUCTIONS: Print this page, complete all sections, and mail or fax the completed form to:

Moolah Shrine Center 12545 Fee Fee Road
St. Louis, MO 63146
Fax: 314-434-5393

PETITION FOR INTERESTS

Created
Elected
Name
Member #
For Office Use Only

Full Name:_______________

Home Phone ______________

Fax __________________

E-Mail _____________________________

Date of Birth ______________

Birthplace ______________

Occupation ________________________________________

Bus. Address ________________________________________

City ______________________________________________

State ____________________

Zip+4 _________________

Bus. Phone ________________

Bus. Fax ____________

Bus E-Mail ________________________________________

Cell Phone ________________

Pager ______________

Wife's Full Name ____________________________________

No. of Children ____________

Ages ______________

Date _____________________________________________

Signature __________________________________________

PLEASE ANSWER THE FOLLOWING:

Were you a DeMolay ?

_____ Yes
_____ No

Chapter and location ? ________________________________

Education _________________________________________

Military Branch ______________________________________

Medical Branch ______________________________________

Pilot (single/multi) _____________________________________

Active License

_____ Yes
_____ No

Please check all that may apply to you

___ Play Golf

___ Bowl

___ Hunt

___ Fish

___ Sing or have sung with an organized group

Who? ____________________________________________

___ Choir

___ Quartet

____Play an instrument

What instruments? ___________________________________

___ Own and instrument

___Own/have owned a horse

___ Own/have owned a motorcycle

___ Computer Proficient

Other special talents and hobbies ________________________

I am interested in more information about the following Moolah Units, Committees and Shrine Clubs (S/C)

___ Air Patrol	___ Amateur Radio	___ Antique Cars
___ Arab Patrol	___ Band	___ Ceremonial Cast
___ Chanters	___ Clowns	___ DeMolay
___ Directors Staff	___ Drum & Bugle	___ Gateway 500 - Mini-Indy's
___ Guides	___ Hospital Committee
___ Legion of Honor	___ Medical Staff	___ Motor Patrol
___ Mounted Lancers	___ Past Masters	___ Pipes & Drums
___ Provost Guard	___ Reception Committee
___ Seniors Club	___ Sound Unit	___ Stage Crew
___ YOMO - Little Yellow Cars
___ Daniel Boone S/C - St. Charles
___ Bootheel S/C - Kennett
___ Cape S/C - Cape Girardeau
___ Capital S/C - Jefferson City
___ CENMO S/C - Viburnum-Bunker-Salem
___ ECMO S/C - Farmington
___ Four Rivers S/C - Union
___ Joachim S/C - Festus-Crystal City
___ Little Dixie S/C - Mexico
___ MIDMO S/C - Montgomery City
___ NEMO S/C - Hannibal
___ North County S/C - St. Louis CO
___ Ozark - Ownensville
___ South County S/C - St. Louis CO
___ SEMO S/C - Sikeston
___ Three Rivers S/C - Poplar Bluff
___ Tiger S/C - Columbia
___ Tri-County S/C - Louisiana

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