How to obtain the Masonic “Gold Award Girl Scout” Certificate

Today’s Date

Name of Recipient:
___________________________________________________________________________________
Address:_________________________________________________________________________________
City:________________________________________State:_______Zip Code:_________________________
Age:_______Grade:________School:__________________________________________________________
Phone:________________________Parent’s E-mail:______________________________________________
Troop/Group Number:____________ ___ ___________ Girl Scout Council: _______________________
Troop/Group Advisor:______________________________________________________________________
Address:_________________________________________________________________________________
City:________________________________________State:_______Zip Code:_________________________
Phone:_______________________________ E-mail:_____________________________________________
Girl Scout Gold Award® Project Advisor: _______________________ Date of Presentation:_____________
Phone:_________________________ E-mail: __________________________________________________
Masonic Information
Grand Lodge’s full name: ___________________________________________________________________
Lodge Name: _____________________________District:_________________________________________
Lodge No.: ____________________ Secretary Phone Number: __________________________________
Address:_________________________________________________________________________________
City:________________________________________State:_______Zip Code:_________________________
Worshipful Master’s Name: __________________________________________________________________
Address:_________________________________________________________________________________
City:________________________________________State:_______Zip Code:_________________________
Lodge Secretary’s Name: ___________________________________________________________________
Address:_________________________________________________________________________________
City:________________________________________State:_______Zip Code:_________________________
Telephone No.:___________________________Email Address:_____________________________________

Submit Application and Check in the amount of $25.00 shipping included

payable to
Grand Lodge of Free and Accepted Masons of the State of New York
71 West 23rd Street
New York, N.Y. 10010
Attn: Lodge Services – 15th Floor

Rev. 9/20