In good standing in ______________________ Lodge No. __________
Located at ___________________________, _____________________. City State Which is a Lodge recognized by or in amity with the conference of Grand Masters of North America. Furthermore,
I have resided at my current address for not less than 6 months, as required by the by-laws of the Imperial Council.
I respectfully pray that I may be made a Noble of the Mystic Shrine, and become a member of your Shrine.
If I be found worthy, and my request granted, I promise to conform to the articles of incorporation and by-laws of the Imperial Council
and the by-laws and ceremonies of your Shrine.

Birthplace: ____________________________ Date of Birth: _______________
Were you ever a DeMolay? ¨ Yes / ¨ No, If so, what was the Chapter Name ____________________
Location: ____________________________
Profession or occupation: ______________________________
Have you previously applied for admission to any Shrine of the Order? _______________
If so, to what Shrine? _____________ When? ________________
Residence Address: ____________________________________________________________________
Street City County State Zip Business Address: ____________________________________________________________________
Street City County State Zip Business Phone No. ___________________ Home Phone No. ___________________
Mail Address: ____________________________________________________________________
Street City County State Zip Wife’s Name: ___________________________________ e-mail address: ______________________
Date: _________________, 20 _______ Signature: ________________________________
Print full Name here: _____________________________________________________
( name in full, initials not sufficient ) Recommended and vouched for on the honor of:
Noble: ____________________________________________
Noble: ____________________________________________
 Do you have a motorcycle license? ¨ Yes / ¨ No
Do you play any musical instrument? ¨ Yes / ¨ No, if so, what? _____________________________
Were you a member of the Armed Forces? ¨ Yes / ¨ No, if so, what branch? ____________________
Do you own a antique car? ¨ Yes / ¨ No
Do you have a desire to become a Shrine clown? ¨ Yes / ¨ No
Are you a license pilot? ¨ Yes / ¨ No
Are you a Past Master of your Lodge? ¨ Yes / ¨ No
Were you ever a member of any Police organization? ¨ Yes / ¨ No
Are you a member of the Scottish Rite? ¨ Yes / ¨ No
Are you a member of the York Rite? ¨ Yes / ¨ No
Are you a member of the Grotto? ¨ Yes / ¨ No
Is your spouse socially inclined? ¨ Yes / ¨ No
Would she consider exploring an organization that supports the Shrine Hospitals? ¨ Yes / ¨ No

E-Mail address______________________________

INSTRUCTIONS FOR THE CANDIDATE FROM THE RECORDER

Candidates must pay full initiation fee and prorated dues, which includes Hospital assessment before being inducted to the Shrine.
Initiation
If Initiated in Dues + Fee = Total
JAN, FEB, MAR $69.00 + $125.00 = $194.00
APR, MAY, JUN $54.00 + $125.00 = $179.00
JUL, AUG, SEP $39.00 + $125.00 = $164.00
OCT, NOV, DEC $24.00 + $125.00 = $149.00

MAKE ALL CHECKS PAYABLE TO: MOHAMMED SHRINE
4201 S. Industry RD
Bartonville, IL 61607-2844