(City or Town)                                                                                                    (Date)

TO THE OFFICERS AND MEMBERS OF THE JACKSONVILLE BODIES:

I, the undersigned certify that I am a Master Mason in good standing in

Lodge No. F. & A. M., located at: , under the jurisdiction of the Grand

 Lodge of   and was raised to that Degree in:

 Lodge No. , located at:     Date Raised:

My occupation, position or trade is that of: 

                                                         (State fully, your occupation, trade or nature of your duties. If retired, from What?)

In connection with or service of: 

(Give name of firm or corporation, or Trade name.)

Name and city of your Consistory: 

My residence is at: Address:    City    Zip Code:

Exact Mailing Address: Address:   City:   Zip Code:

Phone (Work):   Phone: (Res.): Fax:   

Cell Phone:       Email Address:

Date of Birth:

Place of Birth: City:     State:    Country: 

Height - Feet:  inches:    Color of Eyes: Color of Hair:

Married: Yes     No           My wife's name is:        

PLEASE FILL OUT TOP AND BOTTOM                                         

PORTIONS OF THIS FORM.                                                          (Full names, no initials please.)

First Name:    

Middle Name:

Last Name:    

Signature:

                  (Please come into the office and sign)

Received _____________________. Read ____________________. Balloted ___________________

MY PERSONAL REQUEST FOR DEMIT OR CERTIFICATE OF GOOD STANDING

(Please fill out this portion also)

Date:     

TO THE OFFICERS AND MEMBERS OF:

Current Consistory: 

Located at:       City:    State:

Brethren:

    It is my desire to affiliate with the JACKSONVILLE SCOTTISH RITE BODIES of Jacksonville, Florida and I, therefore, request that you issue a -

  DEMIT           CERTIFICATE OF GOOD STANDING

Print Name: 

Sign Name:  

Address:      

City:             

State/zip:      

When issued, please mail direct to: Jacksonville Scottish Rite Masonic Center

                                                     965 Hubbard Street

                                                    Jacksonville, Florida 32206

( This Petition and form may be printed.)