Membership Application

PETITION FOR INITIATION AND MEMBERSHIP
EL JEBEL SHRINE
Shriners International
3443 S. Galena St. Suite 250, Denver, CO 80231
Phone: 303-455-3470 Fax: 303-458-8849
To the Illustrious Potentate, Officers and Nobles of El Jebel Shriners, situated in the Oasis of Denver, Desert of Colorado:
I, the undersigned, do hereby declare that I am a Master Mason in good standing in
Lodge___________________________________________________________________________ Lodge #________________
located at ____________________________________________________ and have been since_________________ which is a
Lodge recognized 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 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 be granted, I promise to
conform to the Articles of Incorporation and Bylaws of The Imperial Council and the Bylaws and Ceremonies of your Temple.
Were you ever a DeMolay? _________ If so, what was the Chapter name and location? _________________________________
Have you previously applied for admission to any temple of the Order? __________ If so, what temple? _____________________
Birthplace __________________________________ Date of Birth ___________________ Profession or
Occupation______________________________________________________________________________________________
Residence Address________________________________________________________________________________________
Business Address_________________________________________________________________________________________
Home Phone ____________________ Business Phone_______________________ E-mail Address _______________________
Send Shrine mail to: _____ Residence OR _____Business
Hat Size (for Fez) ___________ Wife’s Name________________
Signature _________________________________________________
Print Full Name_____________________________________________
A Copy of your current Blue Lodge Card MUST accompany this petition
THIS PETITION MUST BE SIGNED BY TWO NOBLES IN GOOD STANDING IN EL JEBEL
First Line Signer:
EL JEBEL NOBLE___________________________________________ Member #_________________
Address_____________________________________ City____________________________________ State_______________
Phone (
) _________________
Member of Shrine Club/Unit____________________________
Second Line Signer:
EL JEBEL NOBLE________________________________________________ Member #____________
To be completed by El Jebel Office:
Elected_____________________ Created_________________________
Check $__________________ CK#______________/ Visa/MC#_____________________________________________
Exp__________
Member#_____________________________
updated 10/15