State 2020 Annual Application
State
Email address *
I am applying as a/an: *
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Last Name *
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First Name *
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Middle
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Assembly: *
List your current and past titles
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Physical Address *
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City *
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Zip Code (9 Digits) *
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My Mailing Address is the same as my physical address. *
Mailing Address
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City
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Zip Code (9 Digits)
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Home Phone number
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Cell Phone number
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Work Phone number
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Place of Birth *
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Date of Birth *
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DD
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YYYY
Marital Status: *
Name of Spouse (if applicable)
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I am a Member of good standing in the Grand Lodge of
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I am a member of the following Subordinate Lodges : (List all lodges and lodge numbers)
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I am a member of: (OES, Amaranth, White Shrine) list the name and number of each body
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