Petition for Initiation and Membership

Name*
First Last
Address*
Street Address City State ZIP Code
Occupation*
Date of Birth*
MM slash DD slash YYYY
Home Phone*
Cell Phone
Email*
Fez Size*
If you do not know your size, please use this guide (jpg).
Wife's Name
Lady's Cell
Lady's Email
Financial Obligation Due: $165
$165 (includes $100 initiation fee + $65 annual dues) is due to Kem Shriners at the time of initiation.
To the ILLUSTRIOUS POTENTATE, OFFICERS and MEMBERS of KEM SHRINERS, Oasis of Grand Forks, ND, I, the undersigned, hereby declare that I am a Master Mason in good standing of:
Lodge Name:*
Lodge Number:*
Lodge Location (City and State):*
I furthermore represent that I have never applied for said order, nor has any other Shrine oasis rejected me, to the best of my knowledge. If I be found worthy and my request granted, I promise to conform to all the ceremonies, engagements, constitution, regulations and edicts of the Imperial Council together with those of Kem Shriners.
Signed:*

Please type your name in the box above as your signature.

Financial Obligation Due: $165