To the Illustrious Potentate, Officers and Nobles of Ben Ali Shrine Center, situated in the Oasis of Sacramento, California.  I, the undersigned, hereby declare that I am a Master Mason in good standing in ______________________ Lodge No. A.F.&A.M located at ______________________________.

     Furthermore, I do not now, and never will, hold membership in or allegiance to, any Body claiming to be Masonic that has been declared clandestine; that I have resided within the jurisdiction of your temple, or in unoccupied territory, not less than 6 months, as required by the Constitution of The Imperial Council; and that I am not under suspension or expulsion in the Body prerequisite to this Order, and respectfully pray that I may be made a Noble of the Mystic Shrine, and become a member of your Temple.

     If I be found worthy, and my request granted, I promise to conform to all Ceremonies, Engagements, Constitutions, Regulations and Edicts of the Imperial Council together with those of your temple.

Birthplace ____________________________ Date of Birth ____________     Age ____________ 

Profession or occupation _________________________________________   Hat Size ____________

Have you previously applied for admission to any Temple of the Order? ___________

If so, what Temple? ___________________________ When? ___________________

Were you ever a DeMolay? ___ If so, what Chapter?__________________________________________

Profession or occupation _________________________________________
      
Residence Address ________________________________________________

_______________________________________________________________

Mail Address _____________________________________________________


Date _____________20 ____

Signature ________________________________________________________

Print Full Name Here _____________________________________________

Recommended and Vouched for on the Honor of 

Noble ____________________________________________________________

Noble ____________________________________________________________


Return to: Recorder, Ben Ali Shrine Center, 3262 Marysville Blvd. Sacramento California 95821

Phone: Home  ________________________       Work ________________________