PLEASE TYPE OR PRINT ALL INFORMATION
At least $45.00 must accompany an application for a new member. PAYMENT IN FULL IS DUE BEFORE A CANDIDATE JOINS THE REUNION CLASS. IF PAYING BY CREDIT CARD, THE FOLLOWING MUST BE COMPLETED.
CREDIT CARD USED AND NUMBER
___ VISA ___ MC ____ DISCOVER ___ OTHER
Expiration
(MM/YY)
(MM
If the Credit Card Name and Billing Address is different than the personal information supplied above, please contact the Scottish Rite office.
Applications for New Members must be received in the Valley of Peoria Secretary’s office before a Reunion. Affiliations and Dual Memberships can be received and processed at any time.
Mail or Deliver to
SCOTTISH RITE CATHEDRAL
400 NE PERRY AVE.
PEORIA, IL 61603
309-676-4472
Email : valleyofpeoria@ameritech.net
Fax: 309-676-4471
Visit our website: www.valleyofpeoria.org
(Form created August 30, 2004)
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REQUIRED INFORMATION |
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Name: First Middle Last |
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Birthdate: Month Day Year Place of Birth |
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Preferred Mailing Name: |
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Current Street Address (line 1) |
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Current Street Address (line 2) |
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City State Zip —- |
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Employer: Profession Years at Current Address |
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I am currently a Master Mason in good standing in the following Blue Lodge: Name Number State or Country |
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I was raised to the degree of Master Mason in the year in the following Blue Lodge Name Number State or Country |
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(Check One) I am applying for _____ New Membership ______ Affiliation _____ Dual Membership |
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I certify that I am not suspended from the Ancient Accepted Scottish Rite in any Jurisdiction (intial ) . |
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For Affiliations and Dual Memberships ONLY (Check One) I am a _____ Current ____ Demitted member of |
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OPTIONAL INFORMATION Note: Your personal information is not shared outside the Fraternity. |
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Business Address |
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Home Telephone ( ) - Business Telephone ( ) - |
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Cell Phone # ( ) - Fax Number ( |
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Email Address |
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INITIATION DUES and FEES |
US $ |
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Initiation Fees for all Bodies |
$100.00 |
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Picture and Passport |
10.00 |
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Pro-rated Dues—Current Year |
0.00 |
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Pro-rated Dues—Following Year |
0.00 |
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Total Initiation Fees |
$110.00 |
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Affiliation or Dual Membership Fees |
US $ |
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Processing Fees |
$10.00 |
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Pro-Rated Dues—Current Year |
0.00 |
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Total Fees Due |
$10.00 |