Date of Application- ______Name (Please Print) ______

Ancient Accepted Scottish Rite Northern Masonic Jurisdiction, U.S.A., QUALIFICATIONS AND REQUIREMENTS FOR MEMBERSHIP

An applicant for the degrees must be: (1) A resident of a state within the Northern Masonic Jurisdiction (CT, DE, IL, IN, ME, MA, MI, NH, NJ, NY, OH, PA, RI, VT, or WI) (2) A Master Mason in good standing in a Symbolic (Blue) Lodge, recognized by the Supreme Council for the Northern Masonic Jurisdiction of the U.S.A. (3) Recommended by two members of the Scottish Rite of the Northern Masonic Jurisdiction.

Place check next to the Valley to which you wish to join (Initiation Fee as shown): [ ] Evansville [ ] Fort Wayne [ ] George Rogers Clark [ ] Indianapolis [ ] South Bend [ ] Terre Haute $100 $100 $100 $150 $100 $100

I, the undersigned hereof, am desirous of being admitted as a member of this honorable body, and request that I may be received among you.

Date of Birth ______Place of Birth ______NMJ Resident ______years

Occupation ______Firm Name ______

I am a member of ______Lodge Number ______Free & Accepted Masons since the year ______located at

Street ______City ______State______

RECOMMENDED BY (PLEASE PRINT) CANDIDATE SIGNATURE & CONTACT INFORMATION (PLEASE PRINT)

Name ______(Please Review Oath of Fealty On Back of Application Prior To Signing)

Address ______Signature (In Ink)______

City/State ______Zip ______Address ______

Phone Number ______City/State ______Zip ______

Lodge Name & Number ______Phone Number __(______)______

Name ______Cell Phone Number __(______)______

Address ______Work Number ______

City/State ______Zip ______Email ______

Phone Number ______Spouse Name ______

Lodge Name & Number ______Were you a DeMolay? ______If yes, where?______

MILITARY SERVICE RECORD (IF APPLICABLE)

Branch______Start Date______

Discharge Type______End Date______

LODGE CERTIFICATION: I hereby certify that the Brother listed hereon as applicant is a member in good standing of ______Lodge,

Number______, Member #______, under the jurisdiction of the Grand Lodge of ______F. & A.M.

Lodge Secretary Signature ______

FOR OFFICE USE: Initiation Fee $______Dues: $______[ ] Check [ ] Cash [ ] Credit Card

Oath of Fealty

In making this application, I promise on my word of honor that should I be elected and become a member of your honorable

Body, I subscribe to the following.

“I, the undersigned, do hereby promise on my word of honor, and swear true faith, allegiance, and fealty to the Supreme

Council of Sovereign Grand Inspectors General of the Thirty-third and Last Degree of the Ancient Accepted Scottish Rite of

Freemasonry for the Northern Masonic Jurisdiction of the of America, sitting at its Grand East in the town of

Lexington, , and will support and abide by its Constitutions, Orders and Decrees.

“That I will hold allegiance to the said Supreme Council and be loyal thereto, as the supreme authority of the Rite; will hold illegal and spurious every other body that may be established within its Jurisdiction, claiming to be a Supreme Council to which said Supreme Council has not extended due recognition as such; and every other Body of said Rite within the same

Jurisdiction that does not hold its powers from said Supreme Council, or from a Supreme Council recognized by it, and will hold no communication whatever in Scottish Rite Masonry with any member of the same nor allow him to visit any Body of the Rite of which I may be a member; and I will dispense justice to my Brethren according to the laws of equity and honor.

“And should I violate this, my solemn vow and pledge, I consent to be expelled from Scottish Rite Masonry, and all rights therein and in any Body of the Rite, and to be denounced to every Body of the Ancient Accepted Scottish Rite in the world as a traitor and forsworn. “And may God aid me to keep and perform the same. Amen.”

By my signature upon this application, I accept the Oath of Fealty.