Ancient and Accepted Scottish Rite of Freemasonry, Southern Jurisdiction of the United States of Americ: Valley of Kansas City, Orient of ouri To the officers and members ofthe Ancient and sccepted Scotish ite of Freemasonry, in the Valley of Kansas City, Orient of ‘Missouri, Ido hereby respectflly peition forthe degrees, from the 4th to 32nd inclusive, and | promise always fo bear fue Jaith and allegiance (0 the Supreme Council ofthe Thits-third Degree for the Southern Jurisdiction ofthe United States, PEI MATION Name: sn Fist Midale ast (Please print ramet a= do no se ial oF nie) Addéress: : Sheet Gy Sate 3 Big Zip Code Place of Bia Date of Binh: Email Address: TowalComniy State MoniiDay/Vear Home Phone: a Cell Phone: Work Phone ‘Oceupation/Profession: Employed by: i TF rated ines from what pofesion Tete inca from what im T have been a resident in the State oF Missouri for___years. Lady's First Name: _ Baaecead MASONIC INFOR! | am a Master Mason in good standing in: _Lodge#_____ AF. & A.M, Located at: (City /State) cottish Rite Body? C1 Yes 1 No (Yes, state fully when and to what Seottish Rite Body) Have you ever petitioned ALLEGIANCE STATEMENT. ‘The Supreme Council requires acceptance of the following fundamental principles: The inculeation of patriotism, respect for law and order, undying loyalty to the principles of civil and religious liberty, and the entire separation of church and state as set forth in the Constitution of the United States of America. Do you approve wholeheartedly of these principles? Yes No. ave you ever held or expressed opinions contrary to the foregoing or been affiliated with any organization which has? YesC No Ifyou answer this last question inthe affirmative, please explain on a separate sheet of paper, TEES & DUES ‘The total fees and dues for the Ancient and Accepted Scottish Rite Valley of Kansas City are explained on the reverse of ths form. The initiation fee of $175.00 must accompany this Petition with the balance of the fees due at the start of the Reunion. ‘Sign name in full below Do not use initials Date Fee Enclosed ‘Signature ‘This candidate is recommended for membership by the following members ofthe Kansas Cty Valley A.A.S.R. (2 Required) Printed Name and Signature Printed Name and Sienature