DEGREE EXEMPLIFICATION REPORT

TO: SUPREME KNIGHT CARL A. ANDERSON

FROM: DISTRICT DEPUTY NAME____________________________________________
DISTRICT NUMBER __________ JURISDICTION _________________________
DEGREE DATE ________________ HOST COUNCIL NUMBER _____________
ONLY SUBMIT ONE REPORT PER DEGREE. DO NOT REPORT MULTIPLE
DEGREES ON A SINGLE FORM
DEGREE REPORT: TOTAL NUMBER OF CANDIDATES ________________

ADMISSION  STAFF COUNCIL NUMBER: ______________________

ADMISSION DEGREE PRESENTATION: STAFF PRESENTED BY MEMORY 
STAFF READ FROM SCRIPT  STAFF USED CEREMONIAL DVD 

FORMATION  STAFF NAME: ___________________________________________________

KNIGHTHOOD  C.O. NAME: ____________________________________________________

GENERAL
OBSERVATIONS:

PARTICIPATING COUNCILS – CANDIDATES

COUNCIL NUMBER OF COUNCIL NUMBER OF
NUMBER CANDIDATES NUMBER CANDIDATES
__________ ____________ __________ ____________
__________ ____________ __________ ____________
__________ ____________ __________ ____________
__________ ____________ __________ ____________
__________ ____________ __________ ____________

SUBMITTED BY: _____________________________

TITLE ______________________________________

____________________________________________

CC: STATE DEPUTY ____________________________________________

City and State or Province ZIP or Postal Code

450 07/16