Petition for degrees Member No.

____________________
$ _________________
Check No.
____________________
Make check payable to
To the Worshipful Master, Wardens, and Brethren of Cleveland Lodge No. 781
Member Fee $150.00

Cleveland Lodge No. 781 F. & A.M.

The Petition of the Subscriber Respectfully Showeth:
Fee
Enclosed
That he has long entertained a favorable opinion of your Ancient Institution,
and is desirous of being admitted a member thereof, if found worthy;
That he believes in the existence and perfection of God. Date
____________________

Have you ever before petitioned a Lodge of Free and Accepted Masons anywhere? ____ Yes
____ No If you have,
state what Lodge, where situated and when petitioned.
_____________________________________________________________________

_______________________________________________________________________________
Print name below in full, as for example “John Quincy Adams” – If no middle name, list “none”

Name (in full)

_______________________________________________________________________________________________
First Middle Last
Suffix

Address
_________________________________________________________________________________________________
__
City, State, Zip
____________________________________________________________________________________________

His resides at his present address where he has lived since the ______ day of _________________,
_________ (year)

He was born at _______________________________________ on the ______ day of _________________,

_________ (year)
City and State

His occupation is _____________________________________ Place of Business

___________________________________

Address
_________________________________________________________________________________________________
__

Marital Status: Married ___ Wife’s Name ____________________ Divorced _____ Widower ____
Single _____

Phone No. __________________________________________ Cell No.

____________________________________________

Email Address ______________________________________ Recommended by:

Signature __________________________________________________ Bro.
______________________________________
Sign full name, No Initials or Abbreviations – If no middle name, sign “None”

Bro.
______________________________________
Dated at Cleveland, OH on this _____ of ___________, __________

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This portion is for Lodge Use Only

Received ______________________ Committee Notified __________________ Elected _________

Rejected ________
Committee Members
_______________________________ _______________________________
______________________________
Report of Investigating Committee
Favorable ___ Unfavorable ____ Favorable ___ Unfavorable ____ Favorable ___
Unfavorable ____
Initiated Passed Raised
By ___________________________ By ___________________________ By ___________________________
Lecture By _______________________ Lecture By _______________________ Lecture By _______________________
Exam ____________________________ Exam ____________________________ Exam ____________________________
By _____________________________ By _____________________________ By _____________________________