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PETITION FOR INITIATION AND MEMBERSHIP
SYRIA SHRINERS, A.A.O.N.M.S
TO THE POTENTATE, OFFICERS AND NOBLES OF SYRIA SHRINERS A.A.O.N.M.S
SITUATED IN THE OASIS OF CHESWICK, DESERT OF PENNSYLVANIA
I, the undersigned, herby declare that I am a Master Mason in good standing in_________________Lodge #___________
located at________________________________________________________     _________________________________
City State
which is a Lodge recognized by the or in the Conference of Grand Masters of North America. Further more, I have resided
at my current address for not less than 6 months, as required by the Bylaws of The Imperial Council. I respectfully pray
that I may be made a Noble of the Mystic Shrine, and become a member of your temple.
If I be found worthy, and my request granted, I promise to conform to the Articles of Incorporation and Bylaws of The
Imperial Council and the Bylaws and Ceremonies of your temple.
Birthplace_________________________________________________________________  Date of Birth_______________
Profession or occupation_____________________________________________________ Retired____________________
Are you now a member of the Scottish Rite or York Rite? Yes   No  
Were you ever a member of the US Military? Yes   Specify _____________________ No  
Have you previously applied for admission to any Shriner's organization? Yes   No  
If so where? _____________________________________________________ When      
Residence Address                
Street City
         _______________      
County State Zip Code Phone
E-Mail Address ________________________________ Hat Size  
Wife's Name __________________________________
Print
Signature             Date     20______
Print Full Name Here          
Name in Full (Initials not sufficient)
Recommended and Vouched for on the Honor of:
Noble         Card No.     Unit/Club    
Noble         Card No.     Unit/Club    
2006 Fee $175.00 Includes Initiation Fee, Jeweled Fez(2006 pro-rated dues and 2007 dues, Imperial and Hospital assessment) and a
scheduled bus trip and lunch for Candidate and Guest to Erie Shriner's Hospital for Children.
Total Fee to accompany petition  
Make check payable to: Syria Shriners, A.A.O.N.M.S. 1877 Shriners Way Cheswick, PA 15024-1075