M.W.

First Scottish Rite Grand Lodge

P.O. Box 1335
Triborough Station
New York, New York 10035
Org. May 15, 1939
Petition for Initiation and Membership
M.W. Grand Master Ill. Norvell E. Brandon Jr. 330
To the Worshipful Master, Wardens and Brethren of

______________________________________________________Lodge No._________________

The undersigned, unbiased by the inproper solicitation of friends, uninfluenced by mercenary or other unworthy motives and prompted by a favorable opinion and a
desire for knowledge of your Ancient and Honorable Institution, freely and voluntarily offers himself a candidate for themysteries of Freemasonry and respectfully
petitions for initiation and membership in your Lodge, promising a cheerful conformity to the ancient usages and established customs of the Order, and upon his honor, as
a man, has made true answers to the following questions:

What is your full name? ______________________________________________________________________________________________________

1.
What is your Age? ____________________________________ 3. Where were you Born? ________________________________________________
2.
4. Where do you reside? ________________________________________________________________________________________________________
5. State explicitly your business occupation for the past ten years, and where conducted _____________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
6. Beneficiary_____________________________________________ Relationship _________________________________________________________
Address _______________________________________________________________________________________________________________________
Have you resided in the State of _____________________________________ the twelve months last past? __________________________________
7.
Where have you resided the past ten years? If in more than one place, state the particular years in each place and specify your residence during the four
8.
months last past: ____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Have you ever presented a petition to any Masonic Lodge? If so, when and to what Lodge? ________________________________________________
9.
_______________________________________________________________________________________________________________________________

10. Have you ever been rejected by any Masonic Lodge? If so, when and to what Lodge? _____________________________________________________
_______________________________________________________________________________________________________________________________

11. Do you believe in the existence of one ever-living and true GOD? ____________________________________________________________________
12. Amount of Application $ _____________________________________________________
13. Is this application of your own free will? _________________________________________
14. Have yu read allof the questions contained in the foregoing petition? _______________ Are all the answers thereto in your own handwriting?
_________________ And do you, upon your honor, declare your foregoing statements to be true? __________________________________________

15. Name of Church ______________________________________________ Name of Pastor ________________________________________________

Petitioner Phone No. # ___________________________ Signature of Petitioner
__________________________________________________________

Investigated by: _________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________
Medical Report Date _____________________________________ 20 ________
Heart _________________________________ Lungs ______________________________ Blood Pressure _______________________________________
Deformities ________________________________________ Remarks ____________________________________________________________________
Doctor’s Signature _______________________________________________________________________________________________________________
Presented by Bro. __________________________________________________ of the above Lodge who hereby certifies that the petitioner is of good character and reputation and
comes under the tongue of good repute.
Signature _________________________________________________________ Address _____________________________________________________