Complete all sections that apply

Application is hereby made for a Membership Award for:

First Name:  Middle Initial:  Last Name:               Application is made for a 50 Year Pin60 Year Pin70 Year Pin
Expected Date of Presentation:
Born:
Initiated:
Passed:
Raised:
Proficient:
Degrees in Lodge Name:		Lodge No.
Jurisdiction of:
Suspensions:
50 Year Pin Awarded:
60 Year Pin Awarded:
Brother's current address:

Please arrange for presentation by another Grand Jurisdiction or Nebraska Lodge:
		YesNo
It is hereby certified that this Brother is a member in good standing of Lodge No. *

Secretary Name:  *

Secretary Email:   *