This Is to Certify That Brother Was Elected Plural Member of LUZVIMINDA LODGE U. D. on

Form 29 (E-2006)/Plural/ Page 1 of 2

PETITION FOR PLURAL MEMBERSHIP
To the Worshipful Master, Wardens and Brethren of / LUZVIMINDA LODGE U.D.
I, / , the petitioner, submit the following
Print Full Name
information:
Address including Zip Code
Business Address / Occupation
Business Telephone Residence Telephone
Birth Date / Birth Place
Date Initiated / Date Passed / Date Raised
in (lodge name) / Lodge No.
located at / am now in good standing of the following Lodge/Lodges
Lodge No. / Juris.
Lodge No. / Juris.
Lodge No. / Juris.
Certificate of Good of Standing from all Lodges of membership must accompany this petition.
Wife’s maiden name: / Date and Place of Marriage
Names and Address of next of kin:
GOOD STANDING MUST BE MAINTAINED IN ALL LODGES OF MEMBERSHIP, FAILURE TO DO SO WILL RESULT IN LOSS OF MEMBERSHIP IN ALL LODGES.
Dated at / this / day of / AD 20
Recommended By:
1.
2.
3.
(Sign name IN FULL)
Email Address:

To: THE GRAND SECRETARY

This is to certify that Brother was elected plural member of LUZVIMINDA LODGE U. D. on .

Lodge No. / Juris.
Lodge No. / Juris.
Lodge No. / Juris.
NORBERTO C. BAUTISTA, PM - Secretary
No:
PETITION FOR PLURAL MEMBERSHIP
of
Bro.
Referred to Brothers for Investigation
Committee
DATE OF
Reception / 20
Report / 20
Balloting / 20
Result of Ballot

Form 29 (E-2006)/Plural/ Page 2 of 2

Dues for the current year / $ 50.00
Contribution if petitioner is
from another jurisdiction / $ 10.00
Total / $
Investigating Committee forms
Prepared and mailed / 20
Date Committee reported / 20
Petitioner notified of result of ballot on / 20
Signed By-Laws on / 20
If petitioner was declined by the Lodge,
a refund was made on / 20
Warrant No.
Check No.