Petition For Membership

1Basic Information

2Background Information

3Family Information

4Historical Information

5Professional References

6Petition Signers

7Petition Fee Payment

Name*
First Last
Prefered Name
Alternate Names

Please fill this field out if you have ever changed your name or used an alias. Please also indicate where and when it was used.
Residence
Street Address Address Line 2 City State ZIP Code
Age*
Cell Phone
Alternate Phone
Email Address

Petitions to Other Lodges*
- Yes
- No
Have you ever petitioned this or any other Masonic Lodge?
Other Petition Details
Please provide the name of the Lodge, its location, date and result of every petition.
Date
MM slash DD slash YYYY

Current Employer (if retired, enter previous occupation)
Length of Current Employment
Your Current Occupation*
Address of Current Employer
Street Address Address Line 2 City State ZIP Code
Have you ever served in the armed forces?*
- Yes
- No

Family Information
Father's Full Name
First Middle Last Suffix
Mother's Full Name
First Middle Last Suffix
Marrital Status*
- Single
- Married
- Widower
- Divorced
Partner's Name
First Last
If relevant, list your spouses name.
Marriage Date
MM slash DD slash YYYY
Family Masonic Relationships
Please list any family members, and if known include their relationship to you and the name of their lodge and location, if known.

Places of employment for the past 10 years*
Please provide employment history. Including employer, address and job while there.
Have you ever been denied membership in, withdrawn your petition to, or been suspended or expelled from any fraternal organization?
- Yes
- No
Details:
If you answered "Yes," please provide details about the situation.
Do you have any physical impairment?
- Yes
- No
Please let us know if you have a physical impairment or difficulty so we can make accommodations to ensure safety during the degrees.
Details of physical impairment:
If yes, please provide details.
Have you ever been convicted of a criminal offense in a court of competent jurisdiction?*
- Yes
- No
Minor traffic violations are excluded.
Conviction Details
If you answered "yes "and you have been convicted, please provide details of the circumstance.

Please provide three business or professional references we may contact, other than your petition signers.
First Refernece
Name
First Last
Phone
Email
Second Refernece
Name
First Last
Phone
Email
Third Reference
Name
First Last
Phone
Email

Every petition must be signed by two members of the Lodge you are petitioning. They must be members of Millersville Lodge
Petition Signatures*
- I have both a top-line and supporting signer
- I only have a top-line signer, and wish the secretary to request a signature from a brother.
- I don't know have either and would like the secretary to request a signature from two brothers.
If you have two members of Millersville you know, you will list them as your top-line and supporting signer. If not, we can reqeust a brother(s) to sign the petition on your behalf.
Petition for the Degrees of Masonry In Indiana

To the worshipful Master, Wardens and Brethren of
Millersville Lodge No. 126, F & A.M. Indianapolis, IN
I, the undersigned, respectfully represents that having long entertained a favorable opinion of your ancient Institution and having a belief in God, he is desirous of being admitted a member thereof if found worthy. He has resided within the jurisdiction of your Lodge for the period of years and months listed below, next preceding the date of this petition. He has not been rejected by any other Masonic Lodge within the period of one year. The character of the business in which he is engaged as proprietor or employee is also listed below.
Top-Line Signer
Top-Line Signer's Name
First Last
How long has the signer known you?
Supporting Signer
Supporting Signer's Name
First Last
How long has the signer known you?

Certifications
Certification of Truthfulness*
Upon my honor, I certify the truthfulness of my responses.
Certification of Completeness
I have answered all of the questions to the best of my knowledge and with no intentional with holdings or omissions.
Consent*
I agree and consent to the terms of this petition.
Having resided during the past six months within the jurisdiction of the Grand Lodge, F. & A.M., of Indiana, I hereby state that I am an adult
male, believe in the Supreme Being and the immortality of the soul. I am unbiased by friends and uninfluenced by mercenary motives. I hereby
freely and voluntarily offer myself as a candidate for the degrees of Masonry, being prompted to solicit this privilege by a favorable opinion
conceived of the Institution, a desire for knowledge and a sincere wish of being of service to my fellow creatures. Should this petition be granted,
I will cheerfully conform to all the established usages and customs of the Fraternity and abide by its laws, rules and regulations. I have read and
acknowledge the information for the applicant noted at the top of the reverse side of this petition. Also, I certify all information contained on this
application to be accurate as of the date of my signature and acknowledge that any inaccuracies may void this application.
Payment of Petition Fee
Petition Fee*
Price:
Millersville Lodge has a petition fee of $165 which must be submitted with the petition.
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Download Printable Petition

If you would prefer, you may download and print the petition. After you fill it out, just bring it with you to a Tuesday Dinner and a check to cover your petition fee for $135. It can be made out to Millersville Lodge No. 126.

Download

Petition For Membership

Family Information

First Refernece

Second Refernece

Third Reference

Petition for the Degrees of Masonry In Indiana

To the worshipful Master, Wardens and Brethren of Millersville Lodge No. 126, F & A.M. Indianapolis, IN

Top-Line Signer

Supporting Signer

Certifications

Payment of Petition Fee

Download Printable Petition

To the worshipful Master, Wardens and Brethren of
Millersville Lodge No. 126, F & A.M. Indianapolis, IN