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Petition for Initiation and Membership
KHARTUM SHRINERS
To the Potentate, Officers, and Nobles of Khartum Shriners, Situated in the Oasis of Winnipeg, Desert of Manitoba, Canada
I, the undersigned, hereby declare that I am a Master Mason in good standing in __________________Lodge #______located at
____________________________________________________________ __________________________________________________
City
Province
Which is a Lodge recognized by or in amity with the Conference of Grand Masters of North America. Furthermore, I have resided
at my 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 __________________________________________
Were you ever a DeMolay? _____ If so, what was the Chapter name and Location?_____________________________________
Profession or occupation ___________________________________________________________________________________________
Have you previously applied for admission to any temple of the Order? _______________________________________________
If so, what temple?___________________________________
Residence Address _______________________________
Street
_________________________________________________
Province
When? __________________________________________________
_________________________________________________________
City
__________________________________________________________
Postal Code
Business Address __________________________________
Street
__________________________________________________________
City
__________________________________________________ ___________________________________________________________
Province
Postal Code
Business Phone ___________________________________ Hat Size ______________________________________________________
Mail Address ________________________________________________________________________________________________
Home Phone _____________________________________________________________________________________________________
E-Mail Address __________________________________________________________________________________________________
Wife’s Name _____________________________________________________________________________________________________
Fez size __________________ Method of Payment _______________________________________________________________________
Date _________________ 20____ Signature ___________________________________________________________________________
Print Full Name Here _______________________________________________________________________________
Name in full, initials not sufficient
Recommended and Vouched for on the honor of Noble ____________________________ Membership No. _____________
Noble ____________________________ Membership No. _____________
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