Scottish Rite Temple Location 1430 West Braddock Road Alexandria, VA 22302 is NOT a mailing address.

VALLEY OF ALEXANDRIA ORIENT OF VIRGINIA P.O. Box 175 Alexandria, VA 22313-0175

TO THE OFFICERS AND MEMBERS OF THE ALEXANDRIA SCOTTISH RITE BODIES Alexandria Lodge of Perfection, 40 –140 Alexandria Chapter, Knights Rose Croix, 150—180

Date _____________________ Alexandria Council, Knights Kadosh, 190—300 Alexandria Consistory, 310—320

I am a Master Mason in good standing, and respectfully petition to receive the Fourth through Thirty-second degrees, promising to bear true faith and allegiance to The Supreme Council of the Thirty-third Degree for the Southern Jurisdiction of the United States of America.

PLEASE TYPE OR PRINT NAME (In Full) ________________________________________________________ (if no middle name, or initial only, please indicate)

RESIDENCE ADDRESS _________________________________________________ (No., Street, City, State, ZIP Code)

DESIRED MAILING ADDRESS __________________________________________ (if different from above)

BIRTH: DATE _____

___

(Month)

_____ PLACE _______________________________

(Day)

(Year)

WIFE’S NAME

______________________________________________________

OCCUPATION

________________________________________________________ (State type of position, specialty, or profession. If retired state former occupation.)

EMPLOYED BY _______________________________________________________

E-Mail Add: __________________________________________________________ TELEPHONE NO. Home _______________

Cell ________________ Work _______________

BLUE LODGE MEMBERSHIP _____________________________ (No.) __________ Located at (City, State)

___________________________________________________

The Supreme Council announces as fundamental principles the following: “The inculcation of patriotism, respect for law and order and undying loyalty to the Constitution of the United States of America.” Do you approve wholeheartedly of these principles?

 Yes  No

Have you ever held or expressed opinions contrary to the foregoing or been affiliated with any organization which has?  Yes  No If you answer this question in the affirmative, give particulars on reverse side of petition. I have never previously petitioned this or any other Scottish Rite Bodies. (If you have, check here FEES Lodge of Perfection Chapter of Rose Croix Council of Kadosh Consistory Total Fee Includes: 140 Ring, English Patent and Bridge to Light $175.00 Total Fee for Petitioners Under Age 31 A minimum of $90 must accompany this petition. Make check payable to Alexandria Scottish Rite. Amount paid with petition $ ________ Check  Cash  $90.00 45.00 45.00 45.00 $225.00

 and explain on the reverse side.)

——————————————————(Petitioner’s Usual Signature) Recommended by two members of the Alexandria Bodies.

1. _____________________________________ (PLEASE PRINT NAME)

2. _____________________________________ (PLEASE PRINT NAME)