Acca Temple

I hereby declare that I am a Master Mason in good standing in , # , 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 the current address for not less than 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 a member of your temple. 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 your temple.
Birthplace:
Date of Birth:	(dd/mm/yyyy)
Were you ever a DeMolay?(yes)(no) If so, please provide the name, , and location .
Profession or Occupation:
Have you ever previously applied for admission to any temple of the Order?	(yes)(no)
If so, what temple?	when? (dd/mm/yyyy)
Residence Address:
Street:
City:
State:
Zip:
Business Address:
Street:
City:
State:
Zip:
Send Shrine mail to: (check one)
Business Address:	Residence Address:
Business Phone:
Home Phone:
Email address:	(jondoe@globalweb.net)
Wife's Name:

Full Name:
Recommended and Vouched for on the Honor of Noble
The fees for the next ceremonial are:
Billing Information
Card Type:
Card Number:
Expiration Date:	(mm/dd/yyyy)
Name on Card:
Billing Address (If Different from above): Check if Billing Address is the SAME as "residence address" above)
Street:
City:
State:
Zip:
Billing Phone Number:

ONLINE PETITION FOR INITIATION AND MEMBERSHIP