Applicant Information

Name:

Current Address:

City:

Prov/Terr:

Postal Code:

Email:

Website:

Phone (H):

Phone (W):

Other:

Lodge Membership Information

Mother Lodge:

How long?

Lodge Jurisdiction:

Current Rank:

City:

Prov./Terr:

Postal Code:

Phone:

E-mail:

Fax:

Date Initiated:

Passed:

Raised:

Position Currently Held:

Positions Previously Held:

Other Information

If you have ever visited or lived in Inuvik, please provide details here:

I authorize the verification of the information provided on this form as to my current standing in the above lodge, and make application to join The Inuvik Masonic Club. I have attached a copy of a current Lodge Dues card and a Certificate of Good Standing (or equivalent). I have also included payment of Club Dues for the current year ($50.00 CDN) and understand that such dues will be credited to the payment of Lodge Dues once a lodge is formed in Inuvik, NWT.

Signature of Applicant:

Date: