2021Bylaws

Form #4

PETITION FOR RESTORATION

SHRINERS

To the Potentate, Officers and Nobles of Shriners, Situated in the City of

, State of __________________________ : I, the undersigned, as a member of _________________________ Shriners , was suspended for non-payment of dues in the ___________ dues year, and I respectfully request that I be restored to membership in _______________________ Shriners . I have liquidated all indebtedness to _____________________ Shriners , and if my request is granted, I promise to conform to the articles of incorporation and bylaws of Shriners International, together with those of this temple. I furthermore declare that I am a Master Mason in good standing __________________ Lodge, No. ____, located at _______________________, or have otherwise met the prerequisites for membership under the bylaws of Shriners International.

Print Full Name _ ______________________________________________________________

Date of Birth Residence:

Profession / Occupation _____________________ Retired? Yes

Street address, County, City, State, Zip

Mail Address (if different) :

Street address, County, City, State, Zip

Home Phone: Business phone: Spouse’s Name:

Cell phone:

Email:

Email:

Petitioner’s Signature

Date:

20

Recommended by:

Noble

Member No.

181