First Name:    Middle Initial:    Last Name:

Present Address
Address:     City:
State:  Zip:  Phone:

I am a member of: (check all that apply)
Canton Lodge   McKinley Lodge   Trinity Lodge   Lathrop Lodge
Scottish Rite   York Rite   Nazir Grotto
Canton 190 O.E.S.   Delta 539 O.E.S.

New Address
Address:    City:
State:   Zip:   Phone (Include Area Code):

Effective Date:        E-Mail Address:

Note: We can only send you an acknowledgement
of receipt if you supply your E-Mail address

Comments: