Form 140-S - Certificate Of Good Standing Page 2

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(COMPLETE THE FOLLOWING AND ATTACH TO THE CERTIFICATE OF GOOD STANDING)
To the Secretary of__________________________________________Chapter No. ________O.E.S. State of__________________:
Membership record of_________________________________________in______________________________________________
Chapter No.______________is as follow:
Initiated________________________________________
Suspended________________________________________
Demitted_______________________________________
Reinstated_________________________________________
Transferred_____________________________________
Affiliated__________________________________________
Names Changes_________________________________
from__________________________________________
Birth date_______________________________________
_________________________________________________
Secretary
Chapter No._____________
_____________________________
(SEAL)
_________________________________________________
Date
Back Side-Form 140-S
Revised 08/20/2013

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