To the EXCELLENT HIGH PRIEST, KING, SCRIBE and COMPANIONS of Chapter No. , Royal Arch

PETITION FOR AFFILIATION AS A PLURAL OR DUAL MEMBER

CH–16c Revised 20130517

To the EXCELLENT HIGH PRIEST, KING, SCRIBE and COMPANIONS of Chapter No. , Royal Arch Masons of Ohio:

Thispetition of the subscriber respectfully represents that he is a Master Mason in good standing of the lodge listed below and that he is a Royal Arch Mason in good standing of the chapter listed below. A Certificate of Good Standing(Form CH–16d) will be issued by the the secretary of said chapter to the secretary of this chapter. He now prays admission as a member of your chapter, if found worthy.Should this petition be granted, he promises to comply with all the forms, usages, laws, rules, orders and regulations of your chapter and the Grand Chapter of the State of Ohio.

Enter your legal FULL name. Please DO NOT use initials. Also enter your preferred or common name as you wish it to appear on documents and mailings:

First NameFull Middle NameLast NameSuffixPreferred Name

Street AddressCityStateZip Code

Home Phone NumberDate of BirthPlace of BirthLady’s Name

Cell Phone NumberFax Phone NumberEmail Address

Occupation & Co. Name:

Business Street AddressCity, State, ZipBusiness Tele. No.Bus. Fax Ph. No.

Hobbies & Interests:

Masonic Titles & Honors:

I received the degree of Master Mason on , in Lodge No. under the jurisdiction of the Grand Lodge of . I am presently a member of Lodge No. located in under the jurisdiction of the Grand Lodge of . I am a member of Chapter No. under the jurisdiction of the Grand Chapter of.

I have been a resident within the jurisdiction of The Grand Chapter of Royal Arch Masons of Ohio for the six months last past.

Dated this day of, Signature: W. Owense

RECOMMENDED BY:INVESTIGATION REPORT:

W. Owense W. Owense

W. Owense W. Owense

ChapterNo.

W. Owense W. Owense

W. Owense Favorable Unfavorable

ChapterNo.

Petition and Fees Rec’d: Presented: Balloted: Pass Fail