CANDIDATE INFORMATION

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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 ENDORSEMENTS

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

Your Signature*

I authorize the verification of the information provided on this form as to my eligibility for membership.

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Today's Date*