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
www.moolah.org

MOOLAH SHRINERS PERMIT SHEET
Date _________________________
To: Moolah Shrine Center:
______________________(Unit/ Committee/Club) would like
permission to participate in the following activity.
Date Description Sponsor Location
       
       
       
       
       

Submitted By:
Name: __________________________________
Address: __________________________________
Phone: __________________________________
Fax: __________________________________
E-Mail: __________________________________
Approved: __________________________________
Reason for denial: __________________________________
Date: __________________________________
 
This is the ONLY recognized permit sheet to be used for dates outside the Shrine Center. Please notify your members that to receive permission, we must have this form on file to protect you and Moolah.
DENIED DATE:______________________________
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