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
or
email to:  apinkstaff@moolah.org

PETITION FOR INITIATION AND MEMBERSHIP
Created
Elected
Name
Member #
For Office Use Only

Petition For Initiation And Membership Moolah Temple
TO THE POTENTATE, OFFICERS AND NOBLES OF MOOLAH TEMPLE, SITUATED IN THE OASIS OF SAINT LOUIS COUNTY, IN THE DESERT OF MISSOURI I, the undersigned, hereby declare that I am a Master Mason in good standing in _______________________________________ Lodge number ________________
located at City ______________________    State _________
which is a Lodge recognized by or in amity with the Conference of Grand Masters of North America. Furthermore, I have resided at my current address for not less then 6 months, as required by the Bylaws of the Imperial Council. I respectfully pray that I may be made a Noble of the Mystic Shrine, and become an active member of Moolah. If, I be found worthy, and my request granted, I promise to conform to the Articles of Incorporation and Bylaws of the Imperial Council and the Bylaws and Ceremonies of Moolah.
Full Name (print) ___________________  
Home Phone ______________ Fax __________________
E-Mail   _____________________________
Date of Birth   ______________ Birthplace  ______________
Have you ever previously applied for admission to any other temple of the Order ? _____ Yes
_____ No
If so what Temple? ___________________________________
When ______________________
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        ______________
   
Initiation Fee is $200.00 payable to Moolah Shrine Center for the Year of 2004 (includes an embroidered fez, which is mandatory) FULL PAYMENT MUST ACCOMPANY THIS PETITION. -  This does not cover any dues or regalia.
Signature   ______________________________Date _________________
 
Recommended and Vouched for on the Honor of: (must be Moolah Noble)
 
Noble   ____________________ No.   ___________________
Noble   ____________________ No.   ___________________
 
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