Karavan Layout - November 2012 - El Kahir Shrine

SHRINERS INTERNATIONAL
PETITION FOR INITIATION AND MEMBERSHIP
EL KAHIR SHRINE CENTER
CEDAR RAPIDS, IOWA
To the Potentate, Officers and Nobles of El Kahir Shrine, situated in the Oasis of Cedar Rapids, Desert of
Iowa:
I, the undersigned, hereby declare that I am a Master Mason in good standing in _______________Lodge,
No. ____, located at ________________________________.
(see attached copy of Dues card)
Furthermore, I do not now, and never will, hold membership or allegiance to, any body claiming to be
Masonic that has been declared clandestine by the Grand Lodge of Iowa or Grand Lodge of any State. If, I
be found worthy, and my request granted, I promise to conform to the Articles of Incorporation and Bylaws
of International Shrine of North America and the Bylaws and Ceremonies of El Kahir Shrine.
Signature: _______________________________________________________________
(Name in full - Initials Not Sufficient)
Full Name: (Print): ________________________________________________________
Birthplace:_______________________________________Birth Date:_______________
Profession or Occupation: __________________________________________________
Have you previously applied for admission to any Shrine Center? Yes___ No____
If, so, what Shrine Center? _______________________ When:____________________
Residence:
Number & Street: __________________________________________________
City or Town: _____________________________________________________
County:_______________________
State / Zip Code: _______________
Telephone (Home) _______________________ Office/Work:_____________________
Social Security Number: ____________________________ E-Mail: ______________________________
Wife’s Name: ___________________________
Hat or Fez Size: ___________
INITIATION FEES: $300.00
Full Payment must accompany this petition.
Date:______________
No. 1 Sponsoring Noble: _______________________________________________ Number: __________
(Please Print your Names)
No. 2 Sponsoring Noble: _______________________________________________ Number: __________
(Please Print your Names)
Received by El Kahir Shrine Recorder: _______________________________________Date:__________