Most Worshipful Prince Hall Grand Lodge of Ohio

. . . Free and
Accepted Masons

DISPENSATION REQUEST FORM

PLEASE TYPE ONLY

Date: _______________

NAME OF LODGE: ______________________________________ NO:_________________

CONTACT PERSON: _________________________________ TITLE:

___________________________________________

TELEPHONE NUMBER: (.............) ________ - _____________

MAILING ADDRESS: _________________________________________________________

CITY, STATE, ZIP: ___________________________________________________________

DATE(S) REQUESTION: ______________

PLEASE CHECK APPROPRIATE BOX(S)

Initiate Out of Place Dispense With Meeting Due to More Than Constitutional
Holiday Number

Pass Hold Special Meeting Recess For Summer Change Meeting Due to
Holiday

Raise Host District Meeting Hold Election Out of Time Install Officers Out of
Time

Out of Time Hold Election Out of Other (EXPLAIN)

Place

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WORSHIPFUL MASTER

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SECRETARY

*ENCLOSE CHECK or MONEY ORDER AND MAIL TO THE M.W. GRAND MASTER