Petition For Degrees Form Page 2
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2PETITION FOR DEGREES, Page 2
Have you ever been charged, pleaded to, or convicted of a felony? “Yes/No” (Circle Your Answer)
(If Yes, please provide date and place.)
_______________________________________________________________________________________________________________________
My present occupation is _____________________________________
Employer _______________________________________________
Address _______________________________________________________________________________________________________________
[Number, street, apt., city, state, zip-code]
My Supervisor _____________________________________________ Telephone ______________________________________________
Please list employment history for the past FIVE YEARS. (Include service in the armed forces.)
From
To
Employer
Address
Occupation/Title
______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
My references are:
Full Name
Company
Position/Title
Telephone: Residence
Business
Mobile
1. ___________________________________________________________________________________________________________________
2. ___________________________________________________________________________________________________________________
3. ___________________________________________________________________________________________________________________
4. ___________________________________________________________________________________________________________________
5. ___________________________________________________________________________________________________________________
I have served in the Armed Forces “Yes/No” (Circle Your Answer) Branch ______________ From ____________
To ____________
Highest Rank/Grade Attained ____________________ Type of Discharge ___________________ Veteran of __________________
[Combat Service]
Have you been a member of the Order of DeMolay? “Yes/No” (Circle Your Answer)
I have carefully reviewed the statements made by me in this petition, and upon my honor, declare them to be true. I am also aware that the
Grand Lodge of North Carolina will conduct an independent investigation of public records through a consumer reporting agency the fee of which
is included in the cost outlined on this petition and is non-refundable.
Initiation Fee enclosed
$ _________.___
Investigation Fee
$
15.00 (non-refundable)
Total Fee enclosed
$ _________.___
______________________________________________________
[Sign your name in full]
We, the undersigned members of the lodge, personally acquainted with the petitioner, cheerfully recommend the Petitioner as a fit
and proper candidate for the degrees of Masonry.
I have known the petitioner for ______ years _________________________________ / __________________________________________
[Signature]
[Print Full Name]
I have known the petitioner for ______ years _________________________________ / __________________________________________
[Signature]
[Print Full Name]
I do hereby certify that I have checked the foregoing petition against the records in this office and find the following:
_____________________________________________________________________________________________
Dated at Raleigh, N. C.___________
______________________________________________________
[Grand Secretary]
NC Form 17 (rev January 2011)
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