Monthly Membership Change/addition Form
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1MONTHLY MEMBERSHIP CHANGE/ADDITION FORM
TO BE COMPLETED MONTHLY AND MAILED TO THE GRAND SECRETARY’S OFFICE WHEN A
CHANGE/ADDITION IN MEMBERSHIP OCCURS
CHAPTER NAME_______________________________________________ NO.___________________DATE_________________
ADDRESS CHANGE [ ] NAME CHANGE [ ] NEW MEMBER [ ] PLURAL MEMBER [ ] DECEASED [ ]
(Date)
NAME OF MEMBER_________________________________________________ DATE OF BIRTH: _____________________
ADDRESS__________________________________________________________________________________________________
(NO, ST., PO BOX, CITY, STATE, AND ZIP)
PHONE NUMBER: ________________________________
EMAIL: _______________________________________________
INITIATION DATE: __________________ AFFILIATED BY TRANSFER DATE :___________FROM____________________
SUSPENDED DATE: __________________ AFFILIATED BY PLURAL DATE: ____________ FROM _____________________
REINSTATED DATE: _________________ AFFILIATED BY DEMIT DATE:___________ FROM ________________________
DEMIT DATE: _______________________ PLURAL WITHDRAWN DATE: ____________
MASONIC AFFILIATION: ___________________________________________________________________________________
REMARKS:
_________________________________________
SECRETARY
(SEAL)
REVISE 08/20/2013
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
MONTHLY MEMBERSHIP CHANGE/ADDITION FORM
TO BE COMPLETED MONTHLY AND MAILED TO THE GRAND SECRETARY’S OFFICE WHEN A
CHANGE/ADDITION IN MEMBERSHIP OCCURS
CHAPTER NAME_______________________________________________ NO.___________________DATE_______________
ADDRESS CHANGE [ ] NAME CHANGE [ ] NEW MEMBER [ ] PLURAL MEMBER [ ] DECEASED [ ] _____________
(
Date)
NAME OF MEMBER__________________________________________________ DATE OF BIRTH: ____________________
ADDRESS_________________________________________________________________________________________________
(NO., ST., PO BOX, CITY, STATE, AND ZIP)
PHONE NUMBER: ________________________________
EMAIL: ____________________________________________
INITIATION DATE: ___________________ AFFILIATED BY TRANSFER DATE: _________FROM ____________________
SUSPENDED DATE: __________________ AFFILIATED BY PLURAL DATE: __________FROM _____________________
REINSTATED DATE: _________________ AFFILIATED BY DEMIT DATE: __________FROM ________________________
DEMIT DATE: _______________________ PLURAL WITHDRAWN DATE: ______________
MASONIC AFFILATION: ___________________________________________________________________________________
REMARKS:
______________________________________
SECRETARY
(SEAL)
REVISED 08/20/2013
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