2021Bylaws

Form #10

CERTIFICATE OF DISPENSATION

To All True and Faithful Nobles to Whom These Presents Shall Come:

ES SELAMU ALEIKUM

Know Ye , that Shriners International at its 20

annual Imperial Session on

, at

, did by appropriate

action grant this

D I S PE N S AT I O N

to form a temple of the Order to be named _ ___________________________________ Shriners in the City of , State of . Said Shriners to work under Dispensation until after the next Regular Imperial Session of Shriners International in the legal jurisdiction approved by Shriners International. Provisional Officers for the life of this Dispensation to be

Noble _ ___________________________________ , Potentate Noble _ ___________________________________ , Chief Rabban Noble _ ___________________________________ , Assistant Rabban Noble _ ___________________________________ , High Priest and Prophet

Noble _ ___________________________________ , Oriental Guide Noble _ ___________________________________ , Treasurer Noble _ ___________________________________ , Recorder as stated in request for said Dispensation. In Testimony Whereof , we have hereunto subscribed our names and affixed the Seal of Shriners International.

_____________________________________

Attest: ______________________________

—Imperial Potentate

—Imperial Recorder

( seal )

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