MEMBERSHIP PETITION CANDIDATE INFORMATION Candidate Name Candidate Address Candidate City Candidate State Candidate Zip Candidate Phone Candidate Email TEMPLE INFORMATION Shrine Temple Member # Shrine ID# How long have you been a Shriner? Shrine City Shrine State Shrine ZIP Shrine FAX Shrine Email LODGE INFORMATION Lodge Lodge Number Lodge City Lodge State Lodge ZIP Lodge Phone SPOUSE INFORMATION (optional) Spouse Name ACTIVE MEMBER ENDORSMENTS Kops Endorser's Name Kops Endorser's Nickname Kops Endorser's Phone 2nd Kops Endorser's Name 2nd Kops Endorser's Nickname 2nd Kops Endorser's Phone Signature of Noble I authorize the verification of the information provided on this form as to my eligibility for membership. Please write your signature in the box below Today's Date Upon submitting your petition you will be redirected to the DUES & FEES page where you will need to add BOTH the NEW MEMBER FEE ($110.00) and the DUES ($35.00) to your cart for a total of $145.00. Then, checkout. At checkout, your information will need to be re-entered for confirmation and the PayPal Transaction Fee of $4.51 will be added to the total.